The continuing challenge of early mortality in acute pancreatitis

Novel anthropometric indicators of visceral obesity predict the severity of hyperlipidemic acute pancreatitis

BACKGROUND

Obesity substantially contributes to the onset of acute pancreatitis (AP) and influences its progression to severe AP. Although body mass index (BMI) is a widely used anthropometric parameter, it fails to delineate the distribution pattern of adipose tissue. To circumvent this shortcoming, the predictive efficacies of novel anthropometric indicators of visceral obesity, such as lipid accumulation products (LAP), cardiometabolic index (CMI), body roundness index (BRI), visceral adiposity index (VAI), A Body Shape Index (ABSI), and Chinese visceral adiposity index (CVAI) were examined to assess the severity of AP.

METHOD

The body parameters and laboratory indices of 283 patients with hyperlipidemic acute pancreatitis (HLAP) were retrospectively analysed, and the six novel anthropometric indicators of visceral obesity were calculated. The severity of HLAP was determined using the revised Atlanta classification. The correlation between the six indicators and HLAP severity was evaluated, and the predictive efficacy of the indicators was assessed using area under the curve (AUC). The differences in diagnostic values of the six indicators were also compared using the DeLong test.

RESULTS

Patients with moderate to severe AP had higher VAI, CMI, and LAP than patients with mild AP (all P < 0.001). The highest AUC in predicting HLAP severity was observed for VAI, with a value of 0.733 and 95% confidence interval of 0.678-0.784.

CONCLUSIONS

This study demonstrated significant correlations between HLAP severity and VAI, CMI, and LAP indicators. These indicators, particularly VAI, which displayed the highest predictive power, were instrumental in forecasting and evaluating the severity of HLAP.

Bone Marrow Mesenchymal Stem Cells Alleviate Acute Severe Pancreatitis and Promote Lung Repair via Inhibiting NLRP3 Inflammasome in Rat

BACKGROUND

Acute severe pancreatitis (SAP) is a severe acute abdominal disease, which can lead to pancreatic infection and necrosis as well as distant organ damage. Bone marrow mesenchymal stem cells (BMSCs) can exert anti-inflammatory effect on SAP, while NLRP3 inflammasomes play an important role in the inflammatory response. This study aimed to investigate whether BMSCs exert anti-inflammatory effect on SAP by inhibiting NLRP3 inflammasome.

METHODS

The rat SAP model was established. Serum amylase, lipase and inflammatory factor levels were measured by ELISA, and the level of tissue injury was assessed by HE staining. The expression of NLRP3 inflammasome was detected by PCR, Western Blot and immunohistochemistry. ML385 was used to block Nrf2 pathway, aiming to investigate whether Nrf2 pathway was involved in the therapeutic effect of BMSCs on SAP by regulating NLRP3 inflammasome expression.

RESULTS

In SAP rats, NLRP3 inflammasome was activated, which became more evident over time. After transplantation of BMSCs, the NLRP3 inflammasome expression decreased at both mRNA and protein levels, the serum levels of amylase, lipase and inflammatory factors decreased, and the pathological scores of the pancreas and lung were both improved. After blocking the Nrf2 pathway, the NLRP3 inflammasome expression increased in the injured pancreas and lung, and the inflammation deteriorated, which inhibited the therapeutic effects of BMSCs on SAP.

CONCLUSION

The therapeutic effect of BMSC on SAP is at least partially ascribed to the inhibition of NLRP3 inflammasome, and Nrf2 pathway mediates the therapeutic effect of BMSC on SAP by inhibiting NLRP3 inflammasome.

Clinical profile, etiology, and outcome of acute pancreatitis: Experience at a tertiary care center

Background:

Acute pancreatitis (AP) is an inflammatory process of the pancreas with varying degree of involvement of regional tissues. This was a population-based study on the incidence of AP. We aimed to determine the incidence, etiology, and outcome of AP.

Materials and Methodology:

This prospective study was conducted in the Department of Medicine, King George's Medical University, Lucknow, India, on 120 patients of AP. Clinical history, examination, and laboratory investigations were done. Severity of AP was assessed using the modified Atlanta classification.

Results:

A total of 120 patients comprising of 88 men (73.33%) and 32 women (26.66%) were recruited. The mean age of study participant was 36.96 ± 13.44 years. The most common presentation was abdominal pain followed by vomiting. The leading etiological factors were alcohol in 85 patients (70.8%) and gallstones in 25 (20.8%). It was idiopathic 5 patients (4.1%). Mortality was seen in three (2.5%) patients, all of which had severe pancreatitis. Patients with body mass index (BMI) ≥25 kg/m², Hematocrit (HCT) ≥44% and C-reactive protein (CRP) ≥150 mg/l had an increased risk of developing a severe AP.

Conclusions:

Alcohol and gallstones were the most common etiological factors of AP, whereas HCT, CRP, and BMI were the useful predictors of severe pancreatitis.

Acute necrotising pancreatitis: measurements of necrosis volume and mean CT attenuation help early prediction of organ failure and need for intervention

OBJECTIVES

This study explored the early predictive value of volume and mean CT density of necrosis for adverse outcomes in patients with acute necrotising pancreatitis (ANP).

METHODS

A total of 155 patients with ANP who underwent CECT within 7 days of symptom onset were included. The necrosis volume, mean CT density, and modified CT severity index (mCTSI) were calculated. C-reactive protein (CRP) and blood urea nitrogen (BUN) levels both 48 h after symptom onset were reviewed. Adverse outcomes were recorded. The predictive value of each indicator was assessed using ROC curve analysis.

RESULTS

There were significant associations between necrosis volume and mean CT density and organ failure (OF), persistent OF (POF), and need for intervention (p < 0.001 for all). For predicting OF, the area under the curve (AUC) was significantly higher for necrosis volume than for mCTSI and BUN (AUC: 0.84 vs 0.67, p = 0.0011; 0.84 vs 0.71, p = 0.0193, respectively). For predicting POF and need for intervention, the AUCs for necrosis volume were significantly higher than those for mCTSI (AUC: 0.79 vs 0.66, p = 0.0045; 0.77 vs 0.61, p = 0.0019, respectively), but did not significantly differ from those for CRP and BUN. For predicting OF, a significantly better predictive value was achieved with mean CT density than with mCTSI (AUC: 0.79 vs 0.67, p = 0.0163). There were no significant differences in predictive value between mean CT density, CRP, and BUN.

CONCLUSIONS

The volume and mean CT density of necrosis based on CECT can provide early prediction of OF, POF, and need for intervention.

KEY POINTS

• Compared to mCTSI, necrosis volume might be used to more accurately diagnose organ failure and persistent organ failure and might be better associated with the need for intervention. • Necrosis volume and mean CT density based on CECT are reliable quantitative predictors for organ failure, persistent organ failure, and intervention in acute pancreatitis.

Alcohol use disorder and the gut

Acute and chronic gastrointestinal problems are common in the setting of excessive alcohol use, and excessive alcohol use is associated with injury to all parts of the gastrointestinal tract. There is mounting evidence of gastrointestinal injury and increased cancer risk even from moderate alcohol consumption. The major causes of alcohol-related morbidity and mortality within the gastrointestinal system are liver disease, pancreatitis and gastrointestinal cancer. Other alcohol-related intestinal dysfunction is common but not life-threatening, leading to diarrhoea, malabsorption and nutritional deficiencies. This review describes non-neoplastic and neoplastic alcohol-related disorders of the gastrointestinal tract, omitting the liver, which has been reviewed elsewhere.

The Role of Mesenchymal Stem Cells with Ascorbic Acid and N-Acetylcysteine on TNF-α, IL 1β, and NF-κβ Expressions in Acute Pancreatitis in Albino Rats

Severe acute pancreatitis (SAP) is a necrotic pancreatic inflammation associated with high mortality rate (up to 70%). Bone marrow (BM) mesenchymal stem cells (MSCs) have been investigated in pancreatic cellular regeneration, but still their effects are controversial. Therefore, the present study is aimed at examining the enrichment of the stem cells with ascorbic acid (AA) and N-acetylcysteine (NAC) and explore their combined action on the expression of the inflammatory cytokines: interleukin 1β (IL 1β), tumor necrosis factor-α (TNF-α), and nuclear factor-κβ (NF-κβ). A total of twenty adult male Sprague-Dawley albino rats were divided into four groups: the control group, cerulein group (to induce acute pancreatitis), BM-MSCs group, and combined BM-MSCs with AA and NAC group. Homing and proliferation of stem cells were revealed by the appearance of PKH26-labelled BM-MSCs in the islets of Langerhans. AA and NAC combination with BM-MSCs (group IV) was demonstrated to affect the expression of the inflammatory cytokines: IL 1β, TNF-α, and NF-κβ. In addition, improvement of the biochemical and histological parameters is represented in increasing body weight, normal blood glucose, and insulin levels and regeneration of the islet cells. Immunohistochemical studies showed an increase in proliferating cell nuclear antigen (PCNA) and decrease in caspase-3 reactions, detected markedly in group IV, after the marked distortion of the classic pancreatic lobular architecture was induced by cerulein. It could be concluded that treatment with BM-MSCs combined with antioxidants could provide a promising therapy for acute pancreatitis and improve the degeneration, apoptosis, necrosis, and inflammatory processes of the islets of Langerhans. TNF-α, IL 1β, and NF-κβ are essential biomarkers for the evaluation of MSC regenerative effectiveness.

Early intra-abdominal hypertension: A reliable bedside prognostic marker for severe acute pancreatitis

Background and Aim

Severe acute pancreatitis (SAP) is commonly associated with intra-abdominal hypertension (IAH). This acute increase of intra-abdominal pressure (IAP) may be attributed to early organ dysfunction, leading to an increased morbidity and mortality. To assess the incidence of raised IAH and its correlation with other prognostic indicators and various outcomes in SAP.

Methods and Results

This was a prospective observational study in patients of SAP between July 2009 and December 2010. All patients of SAP who were admitted to the hospital within 2 weeks of onset of pain were included in the study. A total of 35 patients with SAP were included in the study. Among these, 25 (71.4%) were males. All our patients had raised IAP; however, IAH was present in 51.4% (18/35). Patients with IAH were found to have a higher APACHE II score (88.9 vs 5.9%; P < 0.001), infectious complications (72.2 vs 5.9%; P < 0.001), circulatory failure (88.9 vs 0%; P < 0.001), and respiratory failure (100 vs 41.2%; P < 0.001). All the eight (22.8%) patients who succumbed to sepsis had IAH. Patients with IAH were found to have a significantly longer intensive care unit (ICU) stay (17.72 vs 12.29 days) and in-hospital stay (24.89 vs 12.29 days).

Conclusion

IAH is a good negative prognostic marker in SAP, seen in up to 51.4%. IAH was found to have a significant negative impact on the outcome in terms of increased mortality, morbidity, in-hospital stay, and ICU stay among the patients of SAP.

Identification of Acute Pancreatitis-Related Genes and Pathways by Integrated Bioinformatics Analysis

BACKGROUND AND AIMS

The present study aimed to identify the differential expressed genes that are related to acute pancreatitis.

METHODS

Microarray datasets GSE109227 and GSE3644 were downloaded from the public database and analyzed to screen the genes. Afterward, integrated analysis of these genes were performed, including gene ontology and pathway enrichment analysis, protein-protein interaction network construction, expression level evaluation in human organs, relevant miRNAs and TFs prediction, and prognosis values of hub genes in pancreatic carcinoma.

RESULTS

A total number of 93 differential expressed genes were screened from the datasets, and EGFR, CDH1, ACTB, CD44, and VCL were identified as hub DEGs. Functional enrichment analysis demonstrated that these genes were mostly enriched in biological processes such as cell adhesion, platelet aggregation, glycoprotein binding, and also involved in multiple pathways included adherent junction, proteoglycans in cancer, bacterial invasion of epithelial cells, focal adhesion, Rap1 signaling pathway, regulation of actin cytoskeleton, and pathways in cancers. The five hub genes were all expressed in human pancreas organs with various levels. Hub gene-related network investigation predicted core miRNAs including hsa-mir-16-5p and main TFs like SOX9 with close interactions with these hub genes. Survival analysis also indicated that the high expression of EGFR, CDH1, ACTB, CD44, and VCL were significantly associated with poor prognosis in pancreatic carcinoma.

CONCLUSIONS

The study suggested that hub genes EGFR, CDH1, ACTB, CD44, and VCL may play vital role in the pathogenesis of acute pancreatitis and may serve as potential biomarkers to facilitate future acute pancreatitis diagnosis and treatment.

Resveratrol improves the therapeutic efficacy of bone marrow-derived mesenchymal stem cells in rats with severe acute pancreatitis

OBJECTIVE

Bone marrow-derived mesenchymal stem cells (BMSCs) are effective in the treatment of severe acute pancreatitis (SAP), but their therapeutic effects could still be improved. In order to optimize the clinical application of BMSCs, we adopted the strategy of resveratrol (Res) pretreatment of BMSCs (Res-BMSCs) and applied it to a rat model of sodium taurocholate (NaT)-induced acute pancreatitis.

METHODS

SAP was induced by injection of 3% NaT into the pancreatic duct and successful induction of SAP occurred after 12 h. Rats were treated with BMSCs, Res or BMSCs primed with Res at 40 mmol/L, Vandetanib (ZD6474) daily oral dosages of 50 mg/kg vandetanib.

RESULTS

Res stimulated BMSCs to secrete vascular endothelial growth factor A (VEGFA), activated the downstream phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway, and inhibited pancreatic cell apoptosis. In addition, conditioned medium (CM) from Res-BMSCs enhanced the proliferation of human umbilical vein endothelial cells (HUVECs) in vitro, increased resistance to apoptosis and promoted the expression of angiogenesis-related proteins CD31, VEGF and VEGFR2 in pancreatic tissue, but Vandetanib partly abolished these effects by blocking the VEGFA- mediated pathway.

CONCLUSION

Resveratrol-preprocessed BMSCs can activate the PI3K/AKT signaling pathway in pancreatic cells and HUVECs through paracrine release of VEGFA; thus, achieving the therapeutic effect of resisting apoptosis of pancreatic cells and promoting regeneration of damaged blood vessels. Res pretreatment may be a new strategy to improve the therapeutic effect of BMSCs on SAP.

Protective Effects of Bone Marrow-Derived Mesenchymal Stem Cells on Insulin Secretion and Inflammation in the Treatment of Severe Acute Pancreatitis in Rats

OBJECTIVE

The present study aims to demonstrate the protective effect of bone marrow mesenchymal stem cells (bmMSCs) on transplanted islets and its potential therapeutic role of severe acute pancreatitis (SAP) in rat model.

MATERIALS AND METHODS

Mesenchymal stem cells (MSCs) were isolated from 6 male SD rats, and were identified. The Islets isolated from 20 SD rats were evenly and randomly divided into co-culture group, and basic culture group (control group), in which the islets were cultured in DMEM/F12 medium, so as to compare the insulin secretion and stimulation index. Severe AP was induced in SD rats by retrograde injection of sodium taurocholate. Ninety rats were randomly and evenly assigned into 5 groups: control group (healthy rats), SAP group, tail vein injection group, intraperitoneal injection group and combined injection (tail vein + intraperitoneal) group. Rats were sacrificed on day 1, 2, and 3. The pancreatic tissues and blood were collected. The plasma levels of IL-10, IL-1β, TNF-α, IL-6 were determined using ELISA. Pathologic changes of the pancreas were observed using HE staining, and the positioning of DAPI labeled bmMSCs in vivo were detected.

RESULTS

Insulin secretion and the stimulation index of co-culture group were significantly higher than those of basic culture group (P < .05), after 7 and 14 days of culture. Inflammation, edema, hemorrhage and necrosis in each model of pancreatitis were reduced significantly in BMMSCs injection group as compared to SAP group (P < .05). Infused BMMSCs through combined injection indicated improved outcome than that of tail-vein injection or intraperitoneal injection alone.

CONCLUSION

Co-culture of BMMSCs with transplanted islets prolongs the survival time of islets and maintains in vitro activity. In the rat model of SAP, combined injection of BMMSCs through tail vein and intraperitoneal significantly suppresses the inflammatory reaction and alleviates pancreatic injury in rat SAP model.

Management of infected pancreatic necrosis in the intensive care unit: a narrative review

BACKGROUND

Severe acute pancreatitis is marked by organ failure and (peri)pancreatic necrosis with local complications such as infected necrosis. Infection of these necrotic collections together with organ failure remain the major causes of admission to an intensive care unit (ICU) in acute pancreatitis. Appropriate treatment of infected necrosis is essential to reduce morbidity and mortality. Overall knowledge of the treatment options within a multidisciplinary team-with special attention to the appropriate use of antimicrobial therapy and invasive treatment techniques for source control-is essential in the treatment of this complex disease.

OBJECTIVES

To address the current state of microbiological diagnosis, antimicrobial treatment, and source control for infected pancreatic necrosis in the ICU.

SOURCES

A literature search was performed using the Medline and Cochrane libraries for articles subsequent to 2003 using the keywords: infected necrosis, pancreatitis, intensive care medicine, treatment, diagnosis and antibiotic(s).

CONTENT

This narrative review provides an overview of key elements of diagnosis and treatment of infected pancreatic necrosis in the ICU.

IMPLICATIONS

In pancreatic necrosis it is essential to continuously (re)evaluate the indication for antimicrobial treatment and invasive source control. Invasive diagnostics (e.g. through fine-needle aspiration, FNA), preferably prior to the start of broad-spectrum antimicrobial therapy, is advocated. Antimicrobial stewardship principles apply: paying attention to altered pharmacokinetics in the critically ill, de-escalation of broad-spectrum therapy once cultures become available, and early withdrawal of antibiotics once source control has been established. This is important to prevent the development of antimicrobial resistance, especially in a group of patients who may require repeated courses of antibiotics during the prolonged course of their illness.

Acute management of pancreatitis: the key to best outcomes

Acute pancreatitis (AP) accounts for over 230 000 US and 28 000 UK hospital admissions annually. Abdominal pain is the most common presenting symptom in AP but may not reflect severity. The clinical challenge is identifying the 20% of patients in whom AP will be severe. We summarise the common aetiologies, the risk stratification strategies including the simplified Bedside Index for Severity in Acute Pancreatitis, acute management approaches in the initial presentation setting, conditions for using advance imaging and opinions on antibiotic use. Some warning signs of impending complications are also discussed.

The product value of serum albumin and prothrombin time activity could be a useful biomarker for severity prediction in AP: An ordinal retrospective study

AIM

To appraise the predictive function of 'the product value of serum albumin and prothrombin time activity' (PAA) on admission for the organ failure related events of acute pancreatitis (AP).

BACKGROUND

789 patients with AP were included in this retrospective study. 468 patients generated transient organ failure (TOF). 242 were diagnosed with persistent organ failure (POF), of which 63 patients died.

STUDY

All the values of laboratory parameters were measured upon admission to hospital. Dunnett'T3 test, Uni- and multi-variate ordinal logistic regression were used. ROC curve was utilized to evaluate the ultimate predictive values.

RESULTS

Among the patients with 4 different levels of severity of acute pancreatitis, PAA observably reduced as the disease aggravated (32.20 vs 29.56 vs 23.54 vs 17.89). PAA was also an independent risk factor for the aggravation of AP (OR: 0.873, 95% CI: 0.848, 0.899; p < 0.01). The Area Under the Curve (AUC) of PAA for OF was 0.828 (0.783, 0.872), 0.828 for POF (0.790, 0.865) and 0.905 for death cases (0.862, 0.948).

CONCLUSION

The product value of serum albumin and prothrombin time activity is a good predictor of the severity, especially the events related to organ failure of acute pancreatitis.

Transient Expression of Interleukin-21 in the Second Hit of Acute Pancreatitis May Potentiate Immune Paresis in Severe Acute Pancreatitis

OBJECTIVES

Interleukin-21 (IL-21) is a cytokine associated with tissue inflammation, autoimmune and infectious diseases. Organ dysfunction and death can occur in patients with acute pancreatitis (AP) in two distinct clinical phases. Initially, a systemic inflammatory response syndrome may be followed by systemic sepsis from infected pancreatic necrosis, known as the "second hit." The expression and possible role of IL-21 in AP has not been established.

METHODS

Thirty-six patients with mild, moderate, and severe AP (SAP) were enrolled. Peripheral blood samples of patients were drawn on days 7, 9, 11, and 13. Reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assay were performed to determine the expression and concentration of IL-21.

RESULTS

Interleukin-21 mRNA levels increased significantly at day 9 in severe (P = 0.002) pancreatitis compared with both the mild and control patient groups. At the protein level, IL-21 was elevated in SAP patients compared with those with mild pancreatitis, although this was not significant. Furthermore, day 9 IL-21 was elevated in septic SAP patients and patients with pancreatic necrosis.

CONCLUSIONS

Interleukin-21 is transiently elevated in SAP compared with the mild/moderate group, and hence IL-21 may contribute to the immune imbalance that occurs in AP.

Inhibiting role of rosiglitazone in the regulation of inflammatory response and protective effects for severe acute pancreatitis in mice

OBJECTIVES

Our study aimed to probe the effects of rosiglitazone treatment on a severe acute pancreatitis (SAP) model induced by caerulein and investigate the underlying mechanism.

METHODS

Differentially expressed messenger RNAs (mRNAs) in the mice of a SAP group were screened out by microarray analysis. The inflammatory response pathway was obtained from the online website DAVID Bioinformatics Resources 6.8. The interactions of caerulein and its target proteins were shown by search tool for interactions of chemicals (STITCH). Functional interactions of the genes associated with pancreatitis and the target proteins of caerulein were obtained with search tool for interactions of chemicals (STRING). SAP mice were established by hourly intraperitoneal injection of caerulein. Rosiglitazone was used as treatment drug, and pancreatic inflammation was assessed. The expression of Socs3 was studied by reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot analysis. The expression of interleukin (IL)-6, IL-1b, and Egr1 were studied by RT-PCR and Western blot analysis.

RESULTS

The GSE77983 data were analyzed, and the results showed that Socs3 was overexpressed in SAP tissues. The inflammation response pathway in pancreas was selected by DAVID, STITCH, and STRING. After injection of rosiglitazone in mice, the serum levels of amylase and lipase were decreased. Furthermore, the mRNA and protein levels of Socs3 and inflammatory cytokines in pancreatic tissues were downregulated.

CONCLUSIONS

Rosiglitazone could protect mice with SAP from injury by downregulating Socs3 and inhibiting the inflammatory response pathway.

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.

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.

WITHDRAWN: Stilamin inhibits intestinal and pancreatic injury in rats with severe acute pancreatitis by down-regulating LCN2 expression

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Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis

OBJECTIVES

Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON.

METHODS

All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy.

RESULTS

Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON.

CONCLUSIONS

Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.

Assessment of PANC3 Score in Predicting Severity of Acute Pancreatitis

Introduction:

Acute pancreatitis is inflammatory process of the pancreas associated with local and systemic complications. At present, there are lots of scores (such as Ransons, APACHE II, bedside index for severity in acute pancreatitis) that help us in predicting severity at the time of admission but these are time consuming or require complex calculation and are costly.

Material and Methods:

PANC3 Scoring System is one of the better systems because the three criteria used (hematocrit, body mass index, and pleural effusion) are simple, easy to assess, readily available, and economic. In this prospective study, 100 cases were evaluated to see the prospects of PANC3 scoring in predicting the severity of acute pancreatitis as decided by modified Marshals score.

Results:

The results showed that PANC3 score had a 96.43% specificity, 75% sensitivity, 80% positive predictive value, and 95.29% negative predictive value.

Conclusion:

Hence, the PANC3 score is a cost-effective, promising score that helps in predicting the severity of acute pancreatitis leading to prompt treatment and early referral to higher center.

Midkine is overexpressed in acute pancreatitis and promotes the pancreatic recovery in L-arginine-induced acute pancreatitis in mice

BACKGROUND AND AIM

Midkine (MK) is involved in the pathogenesis of numerous malignancies, but the expression and effect of MK in acute pancreatitis (AP) have not been well studied and documented.

METHODS

In this study, the expression of MK was assayed in mice with L-arginine-induced AP. A recombinant human MK (rhMK) was introduced in this study to test the effect of MK on the L-arginine-induced AP. Serum amylase and lipase were assayed. Pancreas tissue samples were also collected for the evaluation of histological injury. Western blot and immunochemical staining of α-amylase and proliferating cell nuclear antigen were applied for the study of acinar regeneration in the pancreas.

RESULTS

The elevation of MK expression was found in mice with AP induced by L-arginine. After rhMK administration, rhMK did not affect the severity of acute pancreatic injury in acute phase in L-arginine-induced pancreatitis in mice, in accordance with changes of serum amylase and lipase and the histological evaluation. But during the recovery phase, the area of remaining acinar cells was increased and the fibrosis was reduced in rhMK-treated mice. Furthermore, the expression of proliferating cell nuclear antigen and α-amylase was also upregulated after rhMK treatment.

CONCLUSION

Midkine is over-expressed during AP in the animal model. Recombinant MK could promote the recovery of L-arginine-induced pancreatitis in mice. Therefore, MK may be involved in the regeneration of acinar cells in AP, and rhMK may be a possible therapeutic intervention for the repairment of AP.

Prediction of acute pancreatitis in the earliest stages – role of biochemical parameters and histopathological changes

For many years, there has been a search for a set of biochemical parameters that could facilitate the assessment of severity, prognosis, and administration of early and appropriate treatment in acute pancreatitis. Administration of treatment within the first 48 hours since admission is associated with many problems of distinguishing patients with a mild form of acute pancreatitis (AP) from those with a severe form of acute pancreatitis. Study aim: To assess the relationship between the extent of change in the concentration of 10 selected biochemical indicators: amylase, lipase, total bilirubin, creatinine, uric acid, aspartate transaminase, alanine transaminase, glucose, magnesium, and iron and histopathological lesions in the pancreas within 2 and 6 hours since induction of AP. The selected time periods correspond to the first and the second day of the disease in people, respectively. Material and methods: The experiments were conducted in 110 male Wistar rats weighing from 250 to 300 g. Experimental animals were divided into three groups: Z – a group in which the ranges of the studied factors and histological structure were established; K – a group of animals operated on which were injected with 0.9% NaCl into the biliary-pancreatic duct; E – a group of animals operated on in which acute pancreatitis was induced by an injection of 5% sodium taurocholate into the biliary-pancreatic duct. Animals from the K and E groups were randomly assigned to one of five subgroups from which the material for biochemical and histological examinations was collected at 2 h and 6 h since the induction of AP. Whole pancreases were dissected for histological examinations, and the samples were dyed with hematoxylin and saturated alcoholic eosin solution. The degree of pancreatic lesions was assessed according to the Spormann score. Quantitative variables were characterized by arithmetic means, standard deviations, medians, minimum and maximum values, and 95% CIs. Results: In histological preparations from rats from the E group, after 2 hours, edematous lesions, neutrophilic infiltrations in the pancreatic parenchyma, together with single petechiae started to appear and were observed. After 6 hours, the lesions became more intense, and minor foci of coagulation necrosis and minor foci of purulent inflammation in the fatty tissue appeared. Within 2 hours, statistically significant differences in the amount of four markers: creatinine, ALT, amylase, and magnesium were observed. After six hours, statistically significant differences in the amount of two markers: AST and glucose were seen. The correlations between histological assessments according to the Spormann scale and biochemical indicators were investigated, and it was observed that within 2 hours the intensity of pancreatitis increased together with an increase in AST. In group K, within 6 hours, the intensity of inflammatory infiltration increased together with an increase in creatinine concentration (correlation coefficient 0.95; p=0.0138). In group E, in the period of 2 hours, lesion intensity in the form of inflammatory infiltration increased together with an increase in the AST level (correlation coefficient 0.90; p=0.0063) and an increase in the iron level (correlation coefficient 0.78; p=0.0399). In the same group and in the same period, an increase in the AST level (correlation coefficient 0.79; p=0.0343) was associated with an increase in lesion intensity in the form of ecchymoses. Inflammatory infiltration increased (correlation coefficient -0.87; p=0.0117) within 6 hours, whereas the creatinine level decreased. Interesting results were obtained with the use of regression analysis – forward stepwise regression. In the period of 2 hours, if the creatinine level increased by 1, the intensity of lesions in acute pancreatitis decreased by 9.02, according to the Spormann score, while the other variables remained at a stable level. However, if ALT level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.02, according to the Spormann score; and if the amylase level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.01, according to the Spormann score, while the other variables remained at a stable level. Conclusions: Histopathological lesions occurred prior to changes in laboratory test results, whereas significant correlations with Spormann scores were seen in the case of changes in AST and creatinine levels. The study results confirm the fact that diagnostics in acute pancreatitis is very difficult and requires monitoring of many laboratory parameters.

Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification

The aim of the study was to determine whether extrapancreatic inflammation on computed tomography (EPIC) is helpful in predicting organ failure in the early phase of acute pancreatitis (AP) as defined by the 2012 revised Atlanta classification.Patients (n = 208) who underwent abdominal computed tomography (CT) within 24 hours after AP onset and admission were retrospectively identified. Each patient's EPIC score, Balthazar score, bedside index of severity in acute pancreatitis (BISAP), and systemic inflammatory response syndrome (SIRS) score were obtained. Primary endpoints were organ failure occurrence and death. Scores were evaluated by receiver operator characteristic (ROC) curve and area under the curve (AUC) analysis.Median age was 45 years (range: 18-83 years). Forty-seven patients (22.6%) developed organ failure, and 5 patients (2.4%) developed infection and underwent surgery. Two patients died. The median EPIC score was 2 (range: 0-7). EPIC score accuracy (AUC = 0.724) in predicting organ failure was similar to that of BISAP (0.773) and SIRS (0.801) scores, whereas Balthazar scoring was not significant (P = .293). An EPIC score of 3 or greater had a sensitivity and specificity of 80.65% and 63.16%, respectively. EPIC scores correlated moderately with organ failure severity (Spearman r = 0.321) and number of failed organs (r = 0.343).The EPIC scoring system can be useful in predicting the occurrence of organ failure, but it does not differentiate severity and number of failed organs in early phase AP.

UNDERSTANDING THE INTERNATIONAL CONSENSUS FOR ACUTE PANCREATITIS: CLASSIFICATION OF ATLANTA 2012

Introduction:

Contrast computed tomography and magnetic resonance imaging are widely used due to its image quality and ability to study pancreatic and peripancreatic morphology. The understanding of the various subtypes of the disease and identification of possible complications requires a familiarity with the terminology, which allows effective communication between the different members of the multidisciplinary team.

Aim:

Demonstrate the terminology and parameters to identify the different classifications and findings of the disease based on the international consensus for acute pancreatitis ( Atlanta Classification 2012).

Methods:

Search and analysis of articles in the "CAPES Portal de Periódicos with headings "acute pancreatitis" and "Atlanta Review".

Results:

Were selected 23 articles containing radiological descriptions, management or statistical data related to pathology. Additional statistical data were obtained from Datasus and Population Census 2010. The radiological diagnostic criterion adopted was the Radiology American College system. The "acute pancreatitis - 2012 Rating: Review Atlanta classification and definitions for international consensus" tries to eliminate inconsistency and divergence from the determination of uniformity to the radiological findings, especially the terminology related to fluid collections. More broadly as "pancreatic abscess" and "phlegmon" went into disuse and the evolution of the collection of patient fluids can be described as "acute peripancreatic collections", "acute necrotic collections", "pseudocyst" and "necrosis pancreatic walled or isolated".

Conclusion:

Computed tomography and magnetic resonance represent the best techniques with sequential images available for diagnosis. Standardization of the terminology is critical and should improve the management of patients with multiple professionals care, risk stratification and adequate treatment.

Identifying risk factors for progression to critical care admission and death among individuals with acute pancreatitis: a record linkage analysis of Scottish healthcare databases

OBJECTIVES

Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP.

SETTING

Health boards in Scotland (n=4).

PARTICIPANTS

We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP.

METHODS

Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death.

RESULTS

2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30-39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission.

CONCLUSIONS

National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high.

Intra-Abdominal Pressure Reduction After Percutaneous Catheter Drainage Is a Protective Factor for Severe Pancreatitis Patients With Sterile Fluid Collections

OBJECTIVES

Severe acute pancreatitis (SAP) is a fatal disease with natural course of early SAP (ESAP) and late SAP (LSAP) phases. Peripancreatic percutaneous catheter drainage (PCD) is effective in management of LSAP. Although our previous study indicates that intra-abdominal PCD ahead of peripancreatic PCD benefits ESAP patients with sterile fluid collections, the mechanism is still uncovered.

METHODS

According to therapeutic results, 452 SAP patients who underwent PCD were divided into sterile group (248 cases), secondary infection group (145 cases), and primary infection group (59 cases).

RESULTS

The mortality was 4.1%, 10.9%, and 18.6%, respectively. Logistic-regression analysis indicated that multiorgan dysfunction syndrome (odds ratio [OR], 1.717; 95% confidence interval [95% CI], 1.098-2.685; P = 0.018), catheters located intra-abdominally (OR, 0.511; 95% CI, 0.296-0.884; P = 0.016), and intra-abdominal hypertension (OR, 1.534; 95% CI, 1.016-2.316; P = 0.042) were predictors for infection after PCD. Receiver operating characteristics curve delineated that decrease of intra-abdominal pressure (IAP) of more than 6.5 mm Hg after PCD had the ability to predict infection with sensitivity of 84.0% and specificity of 79.5%.

CONCLUSIONS

Intra-abdominal PCD for acute sterile fluid collections seems to be an effective option rather than peripancreatic PCD. Patients with a significant decrease of IAP had a lower incidence of infection and better alleviation of organ failure.

Mesenchymal stem cell transplantation for treatment of digestive diseases

Treatment of diseases using mesenchymal stem cells (MSCs) has gained great breakthrough with the discovery of properties of MSCs since 1990s. So far, MSC transplantation in the treatment of digestive tract diseases is mainly focused on hepatic cirrhosis, liver failure, acute or chronic pancreatitis, inflammatory bowel disease and digestive tumors. In the current editorial, we rely primarily on the existing evidence to gain a comprehensive perspective toward this area.

Epidemiology, aetiology and outcomes of acute pancreatitis: A retrospective cohort study

BACKGROUND

Acute pancreatitis is a common acute surgical presentation in Western Society. The causes and pattern of pancreatitis has not been previously documented for Western Sydney. As Western Sydney contains many areas of low socio-economic status with an expected high level of alcohol abuse, it was hypothesised that alcoholic pancreatitis would be more prevalent in this population. The aims of this study were to determine the epidemiology, aetiology and outcomes of acute pancreatitis.

METHODS

A retrospective analysis of patients presenting with acute pancreatitis to four tertiary hospitals over a four-year period was undertaken.

RESULTS

932 patients presented with acute pancreatitis with a median age of 50 years (range 16-95); 470 (50.4%) were female. Almost half had gallstones (40%), 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP. 69 (7.4%) of patients were admitted to ICU/HDU, with a median length of stay in ICU was 6 days (range 1-106). 85 (11.1%) patients had severe pancreatitis (score ≥ 3). Mortality in this study was 1% (9).

CONCLUSION

The majority of patients with acute pancreatitis in Western Sydney present with mild disease and have a low risk of morbidity or mortality. The ratio of gallstone to alcohol aetiology was 2:1. Idiopathic pancreatitis is responsible for more cases than expected.

Endoscopic ultrasound-guided transmural drainage of infected pancreatic necrosis developing 2 years after acute pancreatitis

This is a case report of endoscopic ultrasound guided transmural drainage of a large infected pancreatic necrosis. The infected necrosis was treated by placement of a fully covered metal stent with subsequent endoscopic necrosectomy to remove solid debris. The case is notable for the fact that the patient developed infection of a long-standing and previously stable area of walled-off pancreatic necrosis 2 years after it formed. We believe this is the longest time ever reported between necrotizing pancreatitis and the development of infected pancreatic necrosis.

Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis

Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.

Effects of Acupuncture at St25 on Inflammatory Mediators and Nuclear Factor κB Activation in a Rat Model of Severe Acute Pancreatitis

Objective

To observe the effect of electroacupuncture (EA) and manual acupuncture (MA) at ST25 on inflammatory mediators and nuclear factor κ-B (NF-κB) activation in rats with sodium taurocholate-induced severe acute pancreatitis (SAP).

Methods

Eighty-eight male Sprague–Dawley rats were randomly divided into four groups: control (sham-operated), SAP, SAP+EA and SAP+MA (n=22 each). A SAP model was established by injecting 3.5% sodium taurocholate 1 mL/kg into the pancreatic duct. In each group, animals were killed at t=3 h (n=7), 6 h (n=7) and 12 h (n=8) after the procedure. Pancreatic expression of NF-κB was examined by immunohistochemical staining. The levels of tumour necrosis factor α (TNF-α) and interleukin 6 (IL-6) in serum were determined by ELISA. Pathological changes in the pancreas were examined microscopically.

Results

Serum levels of TNF-α and IL-6 increased and morphological changes consistent with tissue damage were observed in the pancreas of SAP rats. NF-κB p65 expression was significantly higher in the SAP group than in the sham-operated group (p<0.05). Treatment with acupuncture at ST25 attenuated morphological damage and reduced levels of TNF-α and IL-6 in serum. NF-κB p65 expression was also significantly reduced by acupuncture at ST25 in the pancreas at 6 and 12 h after the procedure (p<0.05). There were no significant differences between the SAP+EA and SAP+MA groups.

Conclusions

Acupuncture at ST25 might have a therapeutic effect on rats with SAP through inhibition of NF-κB expression and a reduction in the release of pro-inflammatory cytokines.

New tools for optimizing fluid resuscitation in acute pancreatitis

Acute pancreatitis (AP) is a frequent disease with degrees of increasing severity responsible for high morbidity. Despite continuous improvement in care, mortality remains significant. Because hypovolemia, together with microcirculatory dysfunction lead to poor outcome, fluid therapy remains a cornerstone of the supportive treatment. However, poor clinical evidence actually support the aggressive fluid therapy recommended in recent guidelines since available data are controversial. Fluid management remains unclear and leads to current heterogeneous practice. Different strategies may help to improve fluid resuscitation in AP. On one hand, integration of fluid therapy in a global hemodynamic resuscitation has been demonstrated to improve outcome in surgical or septic patients. Tailored fluid administration after early identification of patients with high-risk of poor outcome presenting inadequate tissue oxygenation is a major part of this strategy. On the other hand, new decision parameters have been developed recently to improve safety and efficiency of fluid therapy in critically ill patients. In this review, we propose a personalized strategy integrating these new concepts in the early fluid management of AP. This new approach paves the way to a wide range of clinical studies in the field of AP.

Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification

BACKGROUND

Recent international multidisciplinary consultation proposed the use of local (sterile or infected pancreatic necrosis) and/or systemic determinants (organ failure) in the stratification of acute pancreatitis. The present study was to validate the moderate severity category by international multidisciplinary consultation definitions.

METHODS

Ninety-two consecutive patients with severe acute pancreatitis (according to the 1992 Atlanta classification) were classified into (i) moderate acute pancreatitis group with the presence of sterile (peri-) pancreatic necrosis and/or transient organ failure; and (ii) severe/critical acute pancreatitis group with the presence of sterile or infected pancreatic necrosis and/or persistent organ failure. Demographic and clinical outcomes were compared between the two groups.

RESULTS

Compared with the severe/critical group (n=59), the moderate group (n=33) had lower clinical and computerized tomographic scores (both P<0.05). They also had a lower incidence of pancreatic necrosis (45.5% vs 71.2%, P=0.015), infection (9.1% vs 37.3%, P=0.004), ICU admission (0% vs 27.1%, P=0.001), and shorter hospital stay (15+/-5 vs 27+/-12 days; P<0.001). A subgroup analysis showed that the moderate group also had significantly lower ICU admission rates, shorter hospital stay and lower rate of infection compared with the severe group (n=51). No patients died in the moderate group but 7 patients died in the severe/critical group (4 for severe group).

CONCLUSIONS

Our data suggest that the definition of moderate acute pancreatitis, as suggested by the international multidisciplinary consultation as sterile (peri-) pancreatic necrosis and/or transient organ failure, is an accurate category of acute pancreatitis.

Zinc supplement modulates oxidative stress and antioxidant values in rats with severe acute pancreatitis

Oxidative stress is a main factor in the pathogenesis of severe acute pancreatitis (SAP). The ability of zinc (Zn) to retard oxidative processes has been recognized for many years. This study aims to examine the levels of free oxygen radicals and antioxidant enzyme in SAP rats and know the effect of Zn supplementation on free oxygen radicals and antioxidant system in rats with SAP. Forty-five male Wistar rats were divided into three groups-the SAP group (n=15), the Zn-treated group (n=15), and the controlled group (n=15). For the SAP group, sodium taurocholate is injected into the pancreatic duct to induce SAP; for the Zn-treated group, Zn (5 mg/kg) is subcutaneously injected immediately after injection of 5% sodium taurocholate. Firstly, the activity of erythrocyte glutathione peroxidase (GSH-Px), erythrocyte superoxide dismutase (SOD), and the content of plasma malondialdehyde (MDA), which are the toxic products of oxidative stress, is measured. Secondly, the levels of free oxygen radicals in the liver and kidney are detected. The result showed that the activity of GSH-Px and SOD was lower in the SAP group than that in the controlled group, although the content of plasma MDA increased. However, the activity of SOD and GSH-Px in the Zn-treated group was not significantly decreased after comparing with the controlled group; in the mean time, the content of MDA was not significantly increased either. Moreover, the content of free radical in liver and kidney was higher in the SAP group compared with the controlled group, but the content of free radical in the Zn-treated group was not higher than that in the controlled group (p>0.05). All of the above indicated that Zn may recover the activity of free radical-scavenging enzymes and decrease the content of free radical for the SAP group rats. In conclusion, the content of free radical increase may be one of the reasons that SAP rats are injured, and it is possible for Zn to be used to treat SAP through scavenging free radical and increasing the activity of SOD and GSH-Px of erythrocyte.

Prognostic markers in acute pancreatitis

Acute pancreatitis has a mortality rate of 5-10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

Pharmacological cholinergic stimulation as a therapeutic tool in experimental necrotizing pancreatitis

OBJECTIVES

The endogenous immune response is influenced by the stimulation of the vagal nerve. Stimulation or ablation has a direct impact on the release of pro- and anti-inflammatory mediators. In the progression of acute pancreatitis from local to systemic disease, these mediators play a pivotal role. This study evaluates the effect of pharmacologic stimulation of the cholinergic system on pancreatic damage in experimental necrotizing pancreatitis.

METHODS

Experimental severe necrotizing pancreatitis was induced in male Wistar rats using the glycodeoxycholic acid model. Animals with acute pancreatitis (n = 6) were compared with animals with acute pancreatitis and prophylactic or therapeutic pharmacologic activation of the cholinergic system using nicotine, physostigmine, or neostigmine (n = 36). Twelve hours after the induction of acute pancreatitis, morphological damage as well as the myeloperoxidase levels of the pancreas and the serum levels of high-mobility group box 1 protein were evaluated.

RESULTS

Prophylactic and delayed therapeutic application of nicotine, physostigmine, or neostigmine significantly attenuated the severity of acute pancreatitis 12 hours after the induction of severe necrotizing pancreatitis compared with untreated controls as evaluated with histological scores, myeloperoxidase, and high-mobility group box 1 levels (P < 0.05).

CONCLUSIONS

Stimulation of the cholinergic system is useful to attenuate damage in experimental acute pancreatitis. Not only prophylactic but also delayed application was effective in the present study.

Controversial role of toll-like receptors in acute pancreatitis

Acute pancreatitis (AP) is a common clinical condition with an incidence of about 300 or more patients per million annually. About 10%-15% of patients will develop severe acute pancreatitis (SAP) and of those, 10%-30% may die due to SAP-associated complications. Despite the improvements done in the diagnosis and management of AP, the mortality rate has not significantly declined during the last decades. Toll-like receptors (TLRs) are pattern-recognition receptors that seem to play a major role in the development of numerous diseases, which make these molecules attractive as potential therapeutic targets. TLRs are involved in the development of the systemic inflammatory response syndrome, a potentially lethal complication in SAP. In the present review, we explore the current knowledge about the role of different TLRs that have been described associated with AP. The main candidate for targeting seems to be TLR4, which recognizes numerous damage-associated molecular patterns related to AP. TLR2 has also been linked with AP, but there are only limited studies that exclusively studied its role in AP. There is also data suggesting that TLR9 may play a role in AP.

Parenteral nutrition combined with enteral nutrition for severe acute pancreatitis

Background and Aims. Nutritional support in severe acute pancreatitis (SAP) is controversial concerning the merits of enteral or parenteral nutrition in the management of patients with severe acute pancreatitis. Here, we assess the therapeutic efficacy of gradually combined treatment of parenteral nutrition (PN) with enteral nutrition (EN) for SAP. Methods. The clinical data of 130 cases of SAP were analyzed retrospectively. Of them, 59 cases were treated by general method of nutritional support (Group I) and the other 71 cases were treated by PN gradually combined with EN (Group II). Results. The APACHE II score and the level of IL-6 in Group II were significantly lower than Group I (P < 0.05). Complications, mortality, mean hospital stay, and the cost of hospitalization in Group II were 39.4 percent, 12.7 percent, 32 ± 9 days, and 30869.4 ± 12794.6 Chinese Yuan, respectively, which were significantly lower than those in Group I. The cure rate of Group II was 81.7 percent which is obviously higher than that of 59.3% in Group I (P < 0.05). Conclusions. This study indicates that the combination of PN with EN not only can improve the natural history of pancreatitis but also can reduce the incidence of complication and mortality.

Laboratory diagnosis of acute pancreatitis: in search of the Holy Grail

Acute pancreatitis is an acute inflammatory condition of the pancreas, which might extend to local and distant extrapancreatic tissues. The global incidence varies between 17.5 and 73.4 cases per 100,000 and the pathogenesis recognizes alcohol exposure and biliary tract disease as the leading causes, ahead of post-endoscopic retrograde cholangiopancreatography, drugs and abdominal trauma. The diagnosis of acute pancreatitis is substantially based on a combination of clinical signs and symptoms, imaging techniques and laboratory investigations. Contrast-enhanced computed tomography is the reference standard for the diagnosis, as well as for establishing disease severity. The assessment of pancreatic enzymes, early released from necrotic tissue, is the cornerstone of laboratory diagnosis in this clinical setting. Although there is no single test that shows optimal diagnostic accuracy, most current guidelines and recommendations indicate that lipase should be preferred over total and pancreatic amylase. Although a definitive diagnostic threshold cannot be identified, cut-offs comprised between ≥ 2 and ≥ 4 times the upper limit of the reference interval are preferable. The combination of amylase and lipase has been discouraged as although it marginally improves the diagnostic efficiency of either marker alone, it increases the cost of investigation. Some interesting biomarkers have been also suggested (e.g., serum and urinary trypsinogen-1, -2 and -3, phospholipase A2, pancreatic elastase, procalcitonin, trypsinogen activated protein, activation peptide of carboxypeptidase B, trypsin-2-alpha1 antitrypsin complex and circulating DNA), but none of them has found widespread application for a variety of reasons, including the inferior diagnostic accuracy when compared with the traditional enzymes, the use of cumbersome techniques, or their recent discovery. The promising results of recent proteomics studies showed that this innovative technique might allow the identification of changes characterizing pancreatic tissue injury, thus highlighting new potential biomarkers of acute pancreatitis.

Involvement of thrombopoietin in acinar cell necrosis in L-arginine-induced acute pancreatitis in mice

Thrombopoietin (TPO) plays an important role in injuries of different tissues. However, the role of TPO in acute pancreatitis (AP) is not yet known. The aim of the study was to determine the involvement of TPO in AP. Serum TPO was assayed in necrotizing pancreatitis induced by L-arginine in mice. Recombinant TPO and anti-TPO antibody were given to mice with necrotizing pancreatitis. Amylase, lipase, lactate dehydrogenase, myeloperoxidase activity and pancreatic water content were assayed in serum and tissue samples. Pancreas and lung tissue samples were also collected for histological evaluation. Immunohistochemistry of amylase α and PCNA were applied for the study of acinar regeneration and TUNEL assay for the detection of apoptosis in the pancreas. Increased levels of serum TPO were found in necrotizing pancreatitis. After TPO administration, more severe acinar necrosis was found and blockade of TPO reduced the acinar necrosis in this AP model. Acinar regeneration and apoptosis in the pancreas were affected by TPO and antibody treatment in necrotizing pancreatitis. The severity of pancreatitis-associated lung injury was worsened after TPO treatment, but attenuated after Anti-TPO antibody treatment. In conclusion, serum TPO is up-regulated in the necrotizing pancreatitis induced by L-arginine in mice and may be a risk factor for the pancreatic acinar necrosis in AP. As a pro-necrotic factor, blockade of TPO can attenuate the acinar necrosis in AP and may be a possible therapeutic intervention for AP.

Pathophysiology of acute pancreatitis: potential application from experimental models and human medicine to dogs

The cellular events leading to pancreatitis have been studied extensively in experimental models. Understanding the cellular events and inciting causes of the multisystem inflammatory cascades that are activated with this disease is of vital importance to advance diagnosis and treatment of this condition. Unfortunately, the pathophysiology of pancreatitis in dogs is not well understood, and extrapolation from experimental and human medicine is necessary. The interplay of the inflammatory cascades (kinin, complement, cytokine) is extremely complex in both initiating leukocyte migration and perpetuating disease. Recently, nitric oxide (NO) and altered microcirculation of the pancreas have been proposed as major initiators of inflammation. In addition, the role of the gut is becoming increasingly explored as a cause of oxidative stress and potentiation of systemic inflammation in pancreatitis.

Serum inter-cellular adhesion molecule 1 is an early marker of diagnosis and prediction of severe acute pancreatitis

AIM: To determine if serum inter-cellular adhesion molecule 1 (ICAM-1) is an early marker of the diagnosis and prediction of severe acute pancreatitis (SAP) within 24 h of onset of pain, and to compare the sensitivity, specificity and prognostic value of this test with those of acute physiology and chronic health evaluation (APACHE) II score and interleukin-6 (IL-6).

METHODS: Patients with acute pancreatitis (AP) were divided into two groups according to the Ranson’s criteria: mild acute pancreatitis (MAP) group and SAP group. Serum ICAM-1, APACHE IIand IL-6 levels were detected in all the patients. The sensitivity, specificity and prognostic value of the ICAM-1, APACHE IIscore and IL-6 were evaluated.

RESULTS: The ICAM-1 level in 36 patients with SAP within 24 h of onset of pain was increased and was significantly higher than that in the 50 patients with MAP and the 15 healthy volunteers (P < 0.01). The ICAM-1 level (25 ng/mL) was chosen as the optimum cutoff to distinguish SAP from MAP, and the sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio were 61.11%, 71.42%, 0.6111, 0.7142, 2.1382 and 0.5445, respectively. The area under the curve demonstrated that the prognostic accuracy of ICAM-1 (0.712) was similar to the APACHE-IIscoring system (0.770) and superior to IL-6 (0.508) in distinguishing SAP from MAP.

CONCLUSION: ICAM-1 test is a simple, rapid and reliable method in clinical practice. It is an early marker of diagnosis and prediction of SAP within the first 24 h after onset of pain or on admission. As it has a relatively low NPV and does not allow it to be a stand-alone test for the diagnosis of AP, other conventional diagnostic tests are required.

Infected pancreatic necrosis: Not necessarily a late event in acute pancreatitis

It is widely believed that infection of pancreatic necrosis is a late event in the natural course of acute pancreatitis. This paper discusses the available data on the timing of pancreatic infection. It appears that infected pancreatic necrosis occurs early in almost a quarter of patients. This has practical implications for the type, timing and duration of preventive strategies used in these patients. There are also implications for the classification of severity in patients with acute pancreatitis. Given that the main determinants of severity are both local and systemic complications and that they can occur both early and late in the course of acute pancreatitis, the classification of severity should be based on their presence or absence rather than on when they occur. To do otherwise, and in particular overlook early infected pancreatic necrosis, may lead to a misclassification error and fallacies of clinical studies in patients with acute pancreatitis.

Protective effect of intermedin on myocardial cell in a rat model of severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common disease with a poor prognosis. Heart failure is one cause of SAP patient death. Intermedin (IMD) is a potent endogenous cardio-protective substance. Administration of exogenous IMD showed beneficial effects in cardiovascular diseases. The aim of this study was to investigate the myocardial damage in SAP and to determine the therapeutic potential of IMD for SAP. Using an SAP rat model, we examined endogenous IMD expression following SAP induction, and determined the effect of IMD on myocardial function, histological morphology, apoptosis-related gene expression, and prognosis. Our results indicated that the cardiac function and histological structure were significantly disrupted in SAP rats. Infusion of exogenous IMD significantly preserved cardiac function and ameliorated myocardial damage. Terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) revealed that myocardial apoptosis was extensively present in SAP rats, and IMD infusion led to increased expression of the prosurvival factor Bcl-2, but decreased pro-apoptotic factors Bax and caspase-3. In addition, IMD infusion also reversed the change of IMD receptor systems in SAP rat heart tissue. Furthermore, we found that IMD infusion greatly decreased mortality of SAP rats. In conclusion, administration of SAP produced therapeutic effects in SAP through modulating apoptotic and pro-survival gene expression, inhibiting myocardial apoptosis, preserving cardiac function, and a useful therapeutic agent for SAP, and provides us an insight for a clinical trial of IMD for treating human severe acute pancreatitis.