Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis

The relationship of the microbiome, associated metabolites and the gut barrier with pancreatic cancer

Pancreatic cancers have high mortality and rising incidence rates which may be related to unhealthy western-type dietary and lifestyle patterns as well as increasing body weights and obesity rates. Recent data also suggest a role for the gut microbiome in the development of pancreatic cancer. Here, we review the experimental and observational evidence for the roles of the oral, gut and intratumoural microbiomes, impaired gut barrier function and exposure to inflammatory compounds as well as metabolic dysfunction as contributors to pancreatic disease with a focus on pancreatic ductal adenocarcinoma (PDAC) initiation and progression. We also highlight some emerging gut microbiome editing techniques currently being investigated in the context of pancreatic disease. Notably, while the gut microbiome is significantly altered in PDAC and its precursor diseases, its utility as a diagnostic and prognostic tool is hindered by a lack of reproducibility and the potential for reverse causality in case-control cohorts. Future research should emphasise longitudinal and mechanistic studies as well as integrating lifestyle exposure and multi-omics data to unravel complex host-microbiome interactions. This will allow for deeper aetiologic and mechanistic insights that can inform treatments and guide public health recommendations.

Unveiling the Cuproptosis in Colitis and Colitis-Related Carcinogenesis: A Multifaceted Player and Immune Moderator

Cuproptosis represents a novel mechanism of cellular demise characterized by the intracellular buildup of copper ions. Unlike other cell death mechanisms, its distinct process has drawn considerable interest for its promising applications in managing inflammatory bowel disease (IBD) and colorectal cancer (CRC). Emerging evidence indicates that copper metabolism and cuproptosis may exert dual regulatory effects within pathological cellular environments, specifically modulating oxidative stress responses, metabolic reprogramming, and immunotherapeutic efficacy. An appropriate level of copper may promote disease progression and exert synergistic effects, but exceeding a certain threshold, copper can inhibit disease development by inducing cuproptosis in pathological cells. This makes abnormal copper levels a potential new therapeutic target for IBD and CRC. This review emphasizes the dual function of copper metabolism and cuproptosis in the progression of IBD and CRC, while also exploring the potential application of copper-based therapies in disease treatment. The analysis further delineates the modulatory influence of tumor immune microenvironment on cuproptosis dynamics, while establishing the therapeutic potential of cuproptosis-targeted strategies in circumventing resistance to both conventional chemotherapeutic agents and emerging immunotherapies. This provides new research directions for the development of future cuproptosis inducers. Finally, this article discusses the latest advances in potential molecular targets of cuproptosis and their related genes in the treatment of IBD and CRC, highlighting future research priorities and unresolved issues.

[Pancreatitis from drugs-Drugs for treatment of pancreatitis]

BACKGROUND

Drugs are a rare but important cause of acute pancreatitis (AP) due to potential therapeutic consequences, accounting for up to 5% of all cases of AP. The diagnosis of drug-induced AP is challenging due to mostly weak evidence and complex diagnostic criteria.

OBJECTIVE

This review article defines drug-induced AP, summarizes the evidence for drugs associated with AP and highlights the challenges in the diagnosis of this condition. The second part of the article focuses on the main pillars of AP treatment.

CURRENT DATA

The association of most drugs associated with AP is based on case reports and case series but there are no high-quality studies. There is sufficient evidence of a causal relationship for only 40 of more than 500 drugs associated with AP and for almost none of the drugs the causal mechanism has been definitively clarified. Several classification systems and criteria have been proposed to assess whether a drug causally triggers AP, with criteria including the temporal association, the exclusion of other causes and recurrence of AP after re-exposure.

CONCLUSION

The diagnosis of drug-induced AP remains a challenge, with many common drugs being incorrectly associated with AP. There is an urgent need for the development of biomarkers to facilitate the diagnosis of drug-induced AP. Drug treatment for AP is still primarily a needs-based fluid management and efficient analgesia. New and causal therapeutic approaches need clinical validation.

Histones are critical toxic factors in gut lymph of severe acute pancreatitis: Neutralization by baicalin and baicalein for protection

BACKGROUND

Whether circulating histones in gut lymph contribute to organ failure and impact of chaiqin chengqi decoction (CQCQD) on histones in severe acute pancreatitis (SAP) remain elusive.

PURPOSE

To verify the role of histones in gut lymph of SAP and evaluate the effect of the CQCQD on them.

METHODS

Sodium taurocholate was retrogradely infused into pancreatobiliary duct to induce SAP in rodents. Various regimens of CQCQD were administered intragastrically or via duodenum followed by dynamic gut lymph collection in rats. The impact of gut lymph and histones on endothelial cell viability and lymphocytes was determined. Components of CQCQD in gut lymph were identified by UHPLC-MS and their binding activities with histones were quantified by biolayer interferometry followed by validation in vitro and in vivo in mice.

RESULTS

The histone level was significantly increased in gut lymph of SAP at various time points assessed, closely correlating with multiple organ injury (MOI) indices and contemporary cell viability. Inhibition of histones reduced cytotoxicity induced by SAP-conditioned gut lymph. CQCQD reduced apoptotic cell death in mesenteric lymph nodes, histone level, and cytotoxicity of gut lymph, alleviating MOI parameters. Baicalin and baicalein were amongst top 13 identified CQCQD components absorbed into gut lymph to actively bind histones, block membrane disruption and calcium influx of lymphocytes, and inhibit their cytotoxicity. Both baicalin and baicalein mitigated histone- and SAP-induced MOI indices in mice.

CONCLUSION

Histones are key toxic factors in the gut lymph of SAP and their antagonism by baicalin and baicalein offers a novel therapeutic strategy.

scRNA-seq of the intestine reveals the key role of mast cells in early gut dysfunction associated with acute pancreatitis

BACKGROUND

Intestinal barrier dysfunction is a prevalent and varied manifestation of acute pancreatitis (AP). Molecular mechanisms underlying the early intestinal barrier in AP remain poorly understood.

AIM

To explore the biological processes and mechanisms of intestinal injury associated with AP, and to find potential targets for early prevention or treatment of intestinal barrier injury.

METHODS

This study utilized single-cell RNA sequencing of the small intestine, alongside in vitro and in vivo experiments, to examine intestinal barrier function homeostasis during the early stages of AP and explore involved biological processes and potential mechanisms.

RESULTS

Seventeen major cell types and 33232 cells were identified across all samples, including normal, AP1 (4x caerulein injections, animals sacrificed 2 h after the last injection), and AP2 (8x caerulein injections, animals sacrificed 4 h after the last injection). An average of 980 genes per cell was found in the normal intestine, compared to 927 in the AP1 intestine and 1382 in the AP2 intestine. B cells, dendritic cells, mast cells (MCs), and monocytes in AP1 and AP2 showed reduced numbers compared to the normal intestine. Enterocytes, brush cells, enteroendocrine cells, and goblet cells maintained numbers similar to the normal intestine, while cytotoxic T cells and natural killer (NK) cells increased. Enterocytes in early AP exhibited elevated programmed cell death and intestinal barrier dysfunction but retained absorption capabilities. Cytotoxic T cells and NK cells showed enhanced pathogen-fighting abilities. Activated MCs, secreted chemokine (C-C motif) ligand 5 (CCL5), promoted neutrophil and macrophage infiltration and contributed to barrier dysfunction.

CONCLUSION

These findings enrich our understanding of biological processes and mechanisms in AP-associated intestinal injury, suggesting that CCL5 from MCs is a potential target for addressing dysfunction.

Traditional Chinese medicine Chaiqinchengqi decoction for patients with acute pancreatitis: A randomized clinical trial

BACKGROUND

Chaiqinchengqi decoction, a traditional Chinese medicine, has shown promising effects in in vitro, animal and preliminary small human studies for acute pancreatitis, but evidence of clinical practice is limited.

PURPOSE

To investigate whether Chaiqinchengqi decoction could improve clinical outcomes in patients with acute pancreatitis.

STUDY DESIGN

Prospective, pragmatic, randomized controlled trial. (Chictr.org.cn registration number: ChiCTR2000034325) METHODS: This trial was conducted at West China Hospital of Sichuan University, China. Patients with acute pancreatitis were randomly assigned to receive either Chaiqinchengqi decoction or placebo by oral and rectal enemas in addition to guideline-directed administrations using a 1:1 ratio. The intervention of Chaiqinchengqi and placebo was determined by the grading of acute gastrointestinal injury. Patients were assessed within 24 and 48 hours, and on 3, 5, and 7 days after admission, or organ failure normalized. Survivors were followed up at 1, 3, and 6 months after discharge. Primary outcome was the duration of respiratory failure to 28 days after enrollment. Secondary outcomes included other organ failure, local complications, 6-month all-cause mortality, inflammatory indicators, and related interventions.

RESULTS

Among 248 patients enrolled, Chaiqinchengqi decoction shortened the duration of respiratory failure compared with the placebo (median [IQR], 1.0 [0.0 to 5.0] vs 3.0 [1.0-8.0] days; median difference, -1.0; 95% CI, -2.0 to 0.0, P=.001). There were significant differences in the duration of circulatory failure, the incidence of new-onset respiratory and cardiovascular and failure, the incidence of new organ failure, severity, intensive care unit need, pain visual analogue scale, pancreatitis activity scoring system, and EQ-5D-5L.

CONCLUSION

Chaiqinchengqi decoction as an adjunctive therapy significantly reduced the duration of respiratory failure and improved 6-month clinical outcomes of acute pancreatitis in addition to guideline-directed treatments. Further study is needed to elucidate the mechanism of action.

Chaihuang Qingyi Huoxue granule ameliorates severe acute pancreatitis by modulating gut microbiota and repairing the intestinal mucosal barrier

Background

During severe acute pancreatitis (SAP), damage to the intestinal mucosal barrier and translocation of intestinal pathogenic bacteria are key mechanisms that accelerate the disease progression of SAP. Chaihuang Qingyi Huoxue Granule (CH) is a herbal formula used in the clinical treatment of SAP. This study aims to investigate the role of CH in regulating gut microbiota and intestinal mucosal barrier in SAP rats.

Methods

Sodium taurocholate (3.5%) was retrogradely perfused into the biliopancreatic duct to establish the model of SAP in rats. CH (4.4 g/kg) was administered by gavage. Serum amylase, lipase, and endotoxin levels were measured. Hematoxylin-eosin (HE) staining was used to observe morphological changes in the pancreas and colon. The expression of zona occludens-1 (ZO-1) and occludin in the colon was examined by immunohistochemistry (IHC) and western blot. 16S rDNA gene sequencing was used to analyze the gut microbiota of the rats. The content of short-chain fatty acids (SCFAs) in the intestinal contents of the rats was determined by gas chromatography-mass spectrometry (GC-MS).

Results

CH reduced serum amylase, lipase, and endotoxin levels in SAP rats, alleviated pathological damage in the pancreas and colon, and restored the expression of ZO-1 and occludin. Moreover, CH alleviated gut microbiota dysbiosis in SAP rats, with restored gut microbiota diversity and structure. At the phylum level, the relative abundance of Firmicutes and Bacteroidetes increased, while that of Proteobacteria decreased. At the genus level, the abundance of Ruminococcus 1, Parabacteroides, Prevotellaceae UCG-001, Lachnospiraceae NK4A136 group, and Lactobacillus increased, while that of Escherichia-Shigella, Enterococcus, and Enterobacter decreased. In addition, CH increased the levels of SCFAs in the intestinal contents of SAP rats.

Conclusion

CH ameliorates SAP by maintaining the homeostasis and diversity of the gut microbiota, increasing the levels of SCFAs, and repairing the intestinal mucosal barrier.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis is an inflammatory condition of the exocrine pancreas that is a common indication for hospital admission and has had an increasing incidence in the last few decades. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: (1) abdominal pain radiating to the back, (2) serum lipase or amylase levels three or more times the upper limit of the normal level, and (3) findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI). The different etiologies include gallstones, autoimmune disorders, alcohol abuse, smoking, hypertriglyceridemia, obesity, drugs, and post-endoscope retrograde cholangiopancreatography (ERCP). The initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound. The initial therapy includes oxygen supplementation, the provision of intravenous fluids, pain control, and a nutrition regime. Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes. Some complications of acute pancreatitis are necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation. Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis. The mortality rate of acute pancreatitis has decreased in the past few decades because of better management skills, but the recent rise in acute pancreatitis episodes is concerning. Sustained endeavors through clinical trials are required to establish a broad variety of drugs that can be used for acute pancreatitis episodes.

The effect of blood glucose levels on serum triglyceride clearance in patients with hyperlipidemic acute pancreatitis

Preventing moderately severe and severe acute pancreatitis (MSAP & SAP) is the primary goal of the management of hyperlipidemic acute pancreatitis (HLAP). The main aim of this study was to investigate the factors affecting serum triglyceride (TG) clearance, particularly blood glucose (GLU) levels, which could potentially help to prevent the development of MSAP & SAP. The clinical data from 177 patients with MSAP & SAP and 195 patients with mild acute pancreatitis (MAP) on days 1-6 after the onset were collected and analyzed by multivariate logistic regression to identify the factors that have an impact on the severity of HLAP, especially TG. The optimal TG threshold was obtained by receiver operating characteristic (ROC) analysis to differentiate TG fast-clearance patients from TG slow-clearance patients, as defined in this study. Metabolism-related factors that may interfere with TG clearance, such as GLU, diabetes mellitus (DM), obesity, and uric acid, were further analyzed. Day 2 TG was an independent risk factor for MSAP & SAP in patients with HLAP (OR: 3.718, 95% CI: 2.042-6.77; P < 0.001). And patients with TG slow-clearance (day 2 TG ≥ 7.335 mmol/L) were more likely to develop MSAP & SAP (sensitivity 0.932, specificity 0.898), severe pancreatic necrosis, and death. DM (OR: 3.574, 95% CI: 1.13-11.308, P < 0.001) and day 2 GLU (OR: 1.537, 95% CI: 1.292-1.675; P < 0.001) were independent risk factors for TG slow-clearance but not for HLAP severity (OR: 1.728, P = 0.253 and OR: 1.119, P = 0.059). Day 2 GLU decreased below 13.07 mmol/L and 6.575 mmol/L in patients with DM and non-diabetes mellitus (NDM), respectively, contributing to the reduction of day 2 TG to 7.335 mmol/L. Day 2 TG levels had the most impact on the severity of HLAP, which also accurately predicted the occurrence of MSAP & SAP. It is worth noting whether the GLU can reach the target value on day 2, as it can directly affect the TG clearance rate and indirectly affect the severity of HLAP.

S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

The 1st i-EUS consensus on the management of pancreatic fluid collections - Part 2

Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches. The treatment of patients with PFCs has already focused toward an endoscopy-based approach, and with the development of dedicated lumen-apposing metal stents (LAMS), it has almost totally shifted towards interventional Endoscopic Ultrasound (EUS)-guided procedures. However, there is still limited consensus on several aspects of PFCs treatment within the multidisciplinary management. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript focuses on the second part of the results of a consensus conference organized by i-EUS, with the aim of providing evidence-based guidance on several intra- and post-procedural aspects of PFCs drainage, such as clinical management and follow-up.

Integrating metagenomics with metabolomics for gut microbiota and metabolites profiling in acute pancreatitis

Acute pancreatitis (AP) is an inflammatory disease of the pancreas. Despite of a steadily increasing in morbidity and mortality, there is still no effective therapy. Gut microbial dysbiosis and its derived-metabolites disorder have been shown to play an important role in the development of AP, however, little is known regarding the crosstalk between gut microbiota and metabolites. In this study, we assessed the alterations in gut microbiota and metabolites by constructing three AP mouse models by means of metagenomic and metabolomic sequencing, and further clarified their relationship by correlation analysis. The results revealed that each model exhibited unique flora and metabolite profiles. KEGG analysis showed that the differential flora and metabolite-enriched pathway functions were correlated with lipid metabolism and amino acid metabolism. Moreover, two core differential bacterial species on Burkholderiales bacterium YL45 and Bifidobacterium pseudolongum along with eleven differential metabolites appeared to exert certain effects during the course of AP. In conclusion, further exploration of the crosstalk between microbiota and derived metabolites may provide novel insights and strategies into the diagnosis and treatment of AP.

Effects of Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis

BACKGROUND

The aim of this study was to summarize the optimal strategy for early feeding in patients with acute pancreatitis.

METHODS

The search was undertaken in electronic databases, which compared early with delayed feeding in acute pancreatitis. The primary outcome was the length of hospital stay (LOHS). The second outcomes were intolerance of refeeding, mortality, and total cost of each patient. This meta-analysis followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guideline. Research is registered by PROSPERO, CRD42020192133.

RESULTS

A total of 20 trials involving 2168 patients were included, randomly assigned to the early feeding group (N = 1033) and delayed feeding group (N = 1135). The LOHS was significantly lower in the early feeding group than the delayed feeding group (mean difference: -2.35, 95% CI: -2.89 to -1.80; P < 0.0001), no matter the mild or severe subgroup ( Pint = 0.69). The secondary outcome of feeding intolerance and mortality were no significant difference (risk ratio: 0.96, 0.40 to 2.16, P = 0.87 and 0.91, 0.57 to 1.46, P = 0.69; respectively). Moreover, the hospitalization cost was significantly less in the early feeding group, resulting in an average savings of 50%. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial ( Pint = 0.001).

CONCLUSION

Early oral feeding can significantly reduce the LOHS and hospitalization costs in patients with acute pancreatitis without increasing feeding intolerance or mortality. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial.

Early nasogastric and nasojejunal feeding in patients with predictors of severe acute pancreatitis: а randomized controlled trial

OBJECTIVE: Studying the influence of early nasogastric (NG) and nasojejunal (NJ) probe feeding in patients with predictors of severe acute pancreatitis on the course and outcome of the disease. MATERIALS AND METHODS: An open randomized controlled study was performed in Neftyanik Occupational Healthcare Facility ICU. 64 patients with predictors of severe acute pancreatitis (APACHE II > 8, CRP > 150 mg/l, SOFA > 2) randomized by the envelope method for early (the first 24 hrs.) nasogastic or nasojejunal feeding. The standard polymer feeding formula enriched with dietary fibers was administered during the first 5 (five) days taking into account its tolerability. Raw data were statistically processed using SPSS-26 software. RESULTS: Comparison of the NG (n = 33) vs. NJ (n = 31) groups produced the following results: the duration (days) of treatment in the hospital was 21 (12; 42) vs. 24 (11; 35), p = 0.715; in ICU — 4 (2; 20) vs. 4 (3; 13), p = 0.803; mechanical ventilation (MV) — 1 (1; 3) vs. 1 (1; 1), p = 0.124; mortality — OR 0.830 (95 % CI 0.201–3.422), p = 0.796; severity (moderately severe or severe) — OR 1.29 (95 % CI 0.483–3.448), p = 0.611; number of patients subjected to surgery during the first period of the disease — OR 0.774 (95 % CI 0.243–2.467), p = 0.665; and second period of the disease — OR 1.682 (95 % CI 0.623–4.546), p = 0.305. CONCLUSIONS: No difference has been found between the groups of patients with severe disease predictors, who received early nasogastric or nasojejunal tube feeding using standard polymer formula with dietary fibers during early acute pancreatitis, as regards duration of treatment in the hospital, in ICU, numbers of mechanically ventilated patients, patients operated during the first and second disease periods, disease severity or mortality.

Epidemiology, treatment and outcomes of infected pancreatic necrosis in France: a bicenter study

INTRODUCTION

Acute necrotizing pancreatitis (ANP) mortality increases when pancreatic necrosis is infected (IPN). Current treatment of IPN relies on prolonged antibiotic therapies associated with a step-up strategy of drainage. The objective of this study was to analyze IPN treatment outcomes in two referral centers in France.

METHODS

Data of consecutive patients with documented IPN hospitalized in two expert centers in France between 2014 and 2019 were retrospectively reviewed. The composite primary outcome was the proportion of unsuccessful management outcome, defined as new emergency drainage to treat sepsis with organ failure, an unplanned new antibiotic course, an unplanned prolongation of antibiotic course and/or death by septic shock, within three months following the diagnosis of ANP.

RESULTS

All in all, 187 patients (138 males; 74.0%), with documented IPN were included. The most frequently identified microorganism was Escherichia coli (26.2%). Ninety-eight patients (52.4%) were admitted to an intensive care unit or resuscitation ward within the first two days of ANP care. Overall, 126 patients (67.4%) endured an unsuccessful outcome: new emergency drainage to treat acute sepsis (62.0%), unplanned new antibiotic course (47.1%), unplanned prolongation of antibiotic course (44.9%) and/or death by septic shock complicating IPN (8.0%).

CONCLUSION

The unfavorable evolution in two thirds of patients shows that determination of optimal drainage timing and choice of antibiotic therapy remain major challenges in 2024.

Acute Pancreatitis during and after Pregnancy: A Review

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Exploring the Microbial Landscape: Gut Dysbiosis and Therapeutic Strategies in Pancreatitis-A Narrative Review

The gut microbiota is emerging as an important contributor to the homeostasis of the human body through its involvement in nutrition and metabolism, protection against pathogens, and the development and modulation of the immune system. It has therefore become an important research topic in recent decades. Although the association between intestinal dysbiosis and numerous digestive pathologies has been thoroughly researched, its involvement in pancreatic diseases constitutes a novelty in the specialized literature. In recent years, growing evidence has pointed to the critical involvement of the pancreas in regulating the intestinal microbiota, as well as the impact of the intestinal microbiota on pancreatic physiology, which implies the existence of a bidirectional connection known as the "gut-pancreas axis". It is theorized that any change at either of these levels triggers a response in the other component, hence leading to the evolution of pancreatitis. However, there are not enough data to determine whether gut dysbiosis is an underlying cause or a result of pancreatitis; therefore, more research is needed in this area. The purpose of this narrative review is to highlight the role of gut dysbiosis in the pathogenesis of acute and chronic pancreatitis, its evolution, and the prospect of employing the microbiota as a therapeutic intervention for pancreatitis.

Acute Pancreatitis Induced by COVID-19 Vaccine: A Systematic Review

Acute pancreatitis, marked by sudden inflammation of the pancreas, presents a complex spectrum of causative factors including gallstone obstruction, alcohol abuse, and viral infections. Recent studies have illuminated the emergence of vaccine-induced acute pancreatitis, notably associated with COVID-19 vaccinations, presenting diverse mechanisms ranging from direct viral-mediated injury to autoimmune reactions. Understanding this link is pivotal for public health, yet challenges persist in identifying and managing cases post-vaccination. Comprehensive literature reviews employing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement outline the potential pathways and mechanisms leading to vaccine-induced pancreatitis, emphasizing the need for deeper investigations into underlying health conditions and modifications to vaccine components. Notably, the rare occurrences of vaccine-induced pancreatitis extend beyond COVID-19 vaccines, with reports also documenting associations with measles, mumps, and rubella (MMR), human papillomavirus (HPV), and other viral vaccinations. Mechanistically, hypotheses such as molecular mimicry and immunologic injury have been proposed, necessitating ongoing vigilance and exploration. Regulatory agencies play a crucial role in monitoring and communicating vaccine safety concerns, emphasizing transparency to address potential risks and maintain public trust. Understanding and communicating these rare adverse events with transparency remain integral for informed vaccination policies and to allay concerns surrounding vaccine safety.

Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis

OBJECTIVE

Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission.

DESIGN

Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated.

RESULTS

After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP.

CONCLUSIONS

The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts.

TRIAL REGISTRATION NUMBER

NCT04777812.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

The Interaction of Microbiome and Pancreas in Acute Pancreatitis

Acute pancreatitis (AP) is a common acute abdomen disease characterized by the pathological activation of digestive enzymes and the self-digestion of pancreatic acinar cells. Secondary infection and sepsis are independent prognosticators for AP progression and increased mortality. Accumulating anatomical and epidemiological evidence suggests that the dysbiosis of gut microbiota affects the etiology and severity of AP through intestinal barrier disruption, local or systemic inflammatory response, bacterial translocation, and the regulatory role of microbial metabolites in AP patients and animal models. Recent studies discussing the interactions between gut microbiota and the pancreas have opened new scopes for AP, and new therapeutic interventions that target the bacteria community have received substantial attention. This review concentrates on the alterations of gut microbiota and its roles in modulating gut-pancreas axis in AP. The potential therapies of targeting microbes as well as the major challenges of applying those interventions are explored. We expect to understand the roles of microbes in AP diagnosis and treatment.

Da-Cheng-Qi decoction improves severe acute pancreatitis-associated acute lung injury by interfering with intestinal lymphatic pathway and reducing HMGB1-induced inflammatory response in rats

CONTEXT

Da-Cheng-Qi Decoction (DCQD) has a significant effect on Severe Acute Pancreatitis-Associated Acute Lung Injury (SAP-ALI).

OBJECTIVE

To explore the mechanism of DCQD in the treatment of SAP-ALI based on intestinal barrier function and intestinal lymphatic pathway.

MATERIALS AND METHODS

Forty-five Sprague-Dawley rats were divided into three groups: sham operation, model, and DCQD. The SAP model was induced by a retrograde infusion of 5.0% sodium taurocholate solution (1 mg/kg) at a constant rate of 12 mL/h using an infusion pump into the bile-pancreatic duct. Sham operation and model group were given 0.9% normal saline, while DCQD group was given DCQD (5.99 g/kg/d) by gavage 1 h before operation and 1, 11 and 23 h after operation. The levels of HMGB1, RAGE, TNF-α, IL-6, ICAM-1, d-LA, DAO in blood and MPO in lung were detected using ELISA. The expression of HMGB1, RAGE, NF-κB p65 in mesenteric lymph nodes and lung were determined.

RESULTS

Compared with SAP group, DCQD significantly reduced the histopathological scoring of pancreatic tissue (SAP, 2.80 ± 0.42; DCQD, 2.58 ± 0.52), intestine (SAP, 3.30 ± 0.68; DCQD, 2.50 ± 0.80) and lung (SAP, 3.30 ± 0.68; DCQD, 2.42 ± 0.52). DCQD reduced serum HMGB1 level (SAP, 134.09 ± 19.79; DCQD, 88.05 ± 9.19), RAGE level (SAP, 5.05 ± 1.44; DCQD, 2.13 ± 0.54). WB and RT-PCR showed HMGB1-RAGE pathway was inhibited by DCQD (p < 0.01).

DISCUSSION AND CONCLUSIONS

DCQD improves SAP-ALI in rats by interfering with intestinal lymphatic pathway and reducing HMGB1-induced inflammatory response.

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to 60% and ACS in 15% to 30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiology of IAH/ACS development in patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and the management of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

Colonic mucin-2 attenuates acute necrotizing pancreatitis in rats by modulating intestinal homeostasis

Mucin-2 (MUC2) secreted by goblet cells participates in the intestinal barrier, but its mechanism in acute necrotizing pancreatitis (ANP) remains unclear. In acute pancreatitis (AP) patients, the functions of goblet cells (MUC2, FCGBP, CLCA1, and TFF3) decreased, and MUC2 was negatively correlated with AP severity. ANP rats treated with pilocarpine (PILO) (PILO+ANP rats) to deplete MUC2 showed more serious pancreatic and colonic injuries, goblet cell dysfunction, gut dysbiosis, and bacterial translocation than those of ANP rats. GC-MS analysis of feces showed that PILO+ANP rats had lower levels of butyric acid, isobutyric acid, isovaleric acid, and hexanoic acid than those of ANP rats. The expression of MUC2 was associated with colonic injury and gut dysbiosis. All these phenomena could be relieved, and goblet cell functions were also partially reversed by MUC2 supplementation in ANP rats. TNF-α-treated colonoids had exacerbated goblet cell dysfunction. MUC2 expression was negatively correlated with the levels of pro-inflammatory cytokines (IL-1β and IL-6) (p < .05) and positively related to the expression of tight junction proteins (Claudin 1, Occludin, and ZO1) (p < .05). Downregulating MUC2 by siRNA increased the levels of the pro-inflammatory cytokines in colonoids. MUC2 might maintain intestinal homeostasis to alleviate ANP.

The Role of Short-Chain Fatty Acids in Acute Pancreatitis

Acute pancreatitis (AP) is a digestive emergency and can develop into a systematic illness. The role of the gut in the progression and deterioration of AP has drawn much attention from researchers, and areas of interest include dysbiosis of the intestinal flora, weakened intestinal barrier function, and bacterial and endotoxin translocation. Short-chain fatty acids (SCFAs), as one of the metabolites of gut microbiota, have been proven to be depleted in AP patients. SCFAs help restore gut homeostasis by rebuilding gut flora, stabilizing the intestinal epithelial barrier, and regulating inflammation. SCFAs can also suppress systematic inflammatory responses, improve the injured pancreas, and prevent and protect other organ dysfunctions. Based on multiple beneficial effects, increasing SCFAs is an essential idea of gut protective treatment in AP. Specific strategies include the direct use of butyrate or indirect supplementation through fiber, pre/pro/synbiotics, or fecal microbiota transplantation as a promising adjective therapy to enteral nutrition.

Angiotensin-(1-7) ameliorates intestinal barrier dysfunction by activating the Keap1/Nrf2/HO-1 signaling pathway in acute pancreatitis

BACKGROUND

Intestinal barrier dysfunction is a serious complication associated with acute pancreatitis (AP). Angiotensin (Ang)-(1-7) plays a protective role in the intestinal barrier, but the underlying mechanism remains clear. This study investigated the impact of Ang-(1-7) on AP-induced intestinal dysfunction and its involvement in the Keap1/Nrf2/HO-1 pathway.

METHODS AND RESULTS

We studied caerulein- and lipopolysaccharide (LPS)-induced AP in mice and an epithelial cell line (IEC-6) from the small intestinal crypt of rats. Ang-(1-7) was administered orally or via the tail vein. IEC-6 cells were divided into five groups: control; LPS; LPS + Ang-(1-7); LPS + Ang-(1-7) + ML385 (an Nrf2 inhibitor); and LPS + ML385. Pancreatic and intestinal histopathology scores were analyzed using the Schmidt and Chiu scores. The expression of intestinal barrier-associated proteins and Keap1/Nrf2/HO-1 pathway constituents was assessed by RT-PCR and western blotting. The peroxide and antioxidant activities in the IEC-6 cells were measured. Compared to those in AP mice, Ang-(1-7) diminished the intestinal levels of proinflammatory factors (interleukin-1β and tumor necrosis factor α) and serum levels of intestine permeability (D-lactate). Ang-(1-7) increased the expression of barrier-associated proteins (aquaporin-1, claudin-1, and occludin) compared to those in the AP and LPS group. Moreover, Ang-(1-7) promoted the Keap/Nrf2/HO-1 pathway, which resulted in significantly reduced malondialdehyde and increased superoxide dismutase levels.. However, ML385 abolished the effects of Ang-(1-7) on barrier-associated proteins and reversed the Keap1/Nrf2/HO-1 pathway.

CONCLUSIONS

Ang-(1-7) reduces AP-induced intestinal inflammation and oxidative injuries by activating the Keap1/Nrf2/HO-1 pathway.

Nutrition in acute pancreatitis

Acute pancreatitis (AP) has varying severity, and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions. These patients are at risk of malnutrition. There is no proven pharmacotherapy for AP, however, apart from fluid resuscitation, analgesics, and organ support, nutrition plays an important role in the management of AP. Oral or enteral nutrition (EN) is the preferred route of nutrition in AP, however, in a subset of patients, parenteral nutrition is required. EN has various physiological benefits and decreases the risk of infection, intervention, and mortality. There is no proven role of probiotics, glutamine supplementation, antioxidants, and pancreatic enzyme replacement therapy in patients with AP.

Lactulose regulates gut microbiota dysbiosis and promotes short-chain fatty acids production in acute pancreatitis patients with intestinal dysfunction

BACKGROUND

Intestinal dysfunction is one of the common complications in the early stage of acute pancreatitis (AP), which often associates with bad outcome. Lactulose, as a prebiotic, has been widely used to improve gut health, yet its effect on AP is unclear.

METHODS

This was a prospective, randomized trial of moderate severe AP patients complicated with intestinal dysfunction. A total of 73 participants were randomly assigned to receive either lactulose or Chinese herb rhubarb for 1 week. The primary efficacy endpoint was the recovery of intestinal function. The serum levels of inflammatory cytokines and gut barrier indexes were examined. The fecal samples from patients before and after treatment were collected. 16 S rRNA gene sequencing analysis was performed to explore the composition of gut microbiota and the amount of short-chain fatty acids (SCFAs) were detected by gas chromatography-mass spectrometry (GC-MS).

RESULTS

The intestinal dysfunction was prominently improved after 7 days of treatment with either lactulose or rhubarb. The serum levels of cytokines and gut permeability index were decreased after treatment, with stronger down-regulated degree in lactulose group than rhubarb. The potential beneficial genus Bifidobacterium was enriched in lactulose group, while pathogenic bacteria including Escherichia-Shigella and Neisseria were abundant in rhubarb group. Of note, the level of SCFAs was remarkably increased after treatment, with higher amount in lactulose group than rhubarb group.

CONCLUSIONS

Lactulose could not only restore intestinal function but also regulate gut microbiota and promote the production of SCFAs.

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

Escherichia coli infection indicates favorable outcomes in patients with infected pancreatic necrosis

Introduction

Infected pancreatic necrosis (IPN) is a severe complication of acute necrotizing pancreatitis with increasing morbidity. Escherichia coli is the most frequently cultured microorganism in IPN. However, the implications of Escherichia coli infection on the outcomes of patients with IPN remain unclear. Therefore, this study aimed to evaluate the clinical impacts of Escherichia coli infection on IPN.

Methods

A prospective database with consecutive patients with IPN between January 2010 and April 2022 at a tertiary hospital was post-hoc analyzed. The clinical and microbiological characteristics, surgical management, and follow-up data of patients with and without Escherichia coli infection were compared.

Results

A total of 294 IPN patients were enrolled in this cohort. Compared with non-Escherichia coli infection cases (n=80, 27.2%), patients with Escherichia coli infection (n=214, 72.8%) were characterized by more frequent polymicrobial infections (77.5% vs. 65.0%, P=0.04) but a lower occurrence of severe acute pancreatitis (SAP) (42.5% vs. 61.7%, P=0.003). In addition, significantly lower mortality (12.5% vs. 30.4%, p=0.002), fewer step-up surgical interventions (73.8% vs. 85.1%, P=0.025), and a lower rate of multiple organ failure (MOF) (25.0% vs. 40.2%, P=0.016) were also observed in patients with Escherichia coli infection. Multivariate analysis of mortality predictors indicated that MOF (odds ratio [OR], 6.197; 95% confidence interval [CI], 2.373–16.187; P&lt;0.001) and hemorrhage (OR, 3.485; 95% CI, 1.623–7.487; P=0.001) were independent predictors associated with higher mortality in patients with IPN. Escherichia coli infection was significantly associated with a lower mortality (OR, 0.302; 95% CI, 0.121–0.751; P= 0.01).

Conclusion

Escherichia coli infection indicates a favorable prognosis in patients with IPN, although the mechanism needs further investigation.

Effect of Synbiotics in Reducing the Systemic Inflammatory Response and Septic Complications in Moderately Severe and Severe Acute Pancreatitis: A Prospective Parallel-Arm Double-Blind Randomized Trial

AIM

This study aimed at evaluating the efficacy of synbiotics in reducing septic complications in moderately severe and severe acute pancreatitis.

METHODS

This was a prospective, parallel-arm, double-blinded superiority randomized control study. All patients with moderately severe and severe acute pancreatitis were included in the study. Acute on chronic pancreatitis, pancreatitis due to trauma, ERCP and malignancy were excluded. 1 g of synbiotic containing both pre- and probiotics was administered to the cases twice a day for 14 days and a similar-looking placebo to controls. Patients were followed for 90 days. Primary outcomes were reduction of septic complications and inflammatory marker levels. Secondary outcomes were mortality, non-septic morbidity, length of hospitalization (LOH) and need for intervention.

RESULTS

A total of 86 patients were randomized to 43 in each arm. Demographic profile and severity of pancreatitis were comparable. There was no significant difference in septic complications between the groups (59% vs. 64%; p 0.59). Total leucocyte and neutrophil counts showed a significant reduction in the first 7 days (p = 0.01 and 0.05). No significant difference was seen in other inflammatory markers. There was a significant reduction in the LOH (10 vs. 7; p = 0.02). Non-septic morbidity (41% vs. 62.2%; p 0.06) and length of ICU stay (3 vs. 2; p 0.06) had a trend towards significance. The need for intervention and mortality was comparable.

CONCLUSION

Synbiotics did not significantly reduce the septic complications in patients with moderately severe and severe acute pancreatitis; however, they significantly reduced the LOH. There was no reduction in mortality and need for intervention. Clinical Trials Registry of India Number: CTRI/2018/03/012597.

Monocytic HLA-DR Expression in Immune Responses of Acute Pancreatitis and COVID-19

Acute pancreatitis is a common gastrointestinal disease with increasing incidence worldwide. COVID-19 is a potentially life-threatening contagious disease spread throughout the world, caused by severe acute respiratory syndrome coronavirus 2. More severe forms of both diseases exhibit commonalities with dysregulated immune responses resulting in amplified inflammation and susceptibility to infection. Human leucocyte antigen (HLA)-DR, expressed on antigen-presenting cells, acts as an indicator of immune function. Research advances have highlighted the predictive values of monocytic HLA-DR (mHLA-DR) expression for disease severity and infectious complications in both acute pancreatitis and COVID-19 patients. While the regulatory mechanism of altered mHLA-DR expression remains unclear, HLA-DR-/low monocytic myeloid-derived suppressor cells are potent drivers of immunosuppression and poor outcomes in these diseases. Future studies with mHLA-DR-guided enrollment or targeted immunotherapy are warranted in more severe cases of patients with acute pancreatitis and COVID-19.

Obesity Worsens Local and Systemic Complications of Necrotizing Pancreatitis and Prolongs Disease Course

BACKGROUND

Obesity is epidemic in the USA. Limited data exist examining obesity's influence on necrotizing pancreatitis (NP) disease course.

METHODS

Retrospective review of prospectively maintained database of 571 adult necrotizing pancreatitis patients treated between 2007 and 2018. Patients were grouped according to body mass index (BMI) at disease onset. Patient characteristics, necrotizing pancreatitis course, and outcomes were compared between non-obese (BMI < 30) and obese (BMI > 30) patients.

RESULTS

Among 536 patients with BMI data available, 304 (57%) were obese (BMI > 30), and 232 (43%) were non-obese (BMI < 30). NP etiology in the obese group was more commonly biliary (55% versus 46%, p = 0.04) or secondary to hypertriglyceridemia (10% versus 2%, p < 0.001) and less commonly alcohol (17% versus 26%, p = 0.01). Obese patients had a higher incidence of baseline comorbid disease. The CT severity index was similar between groups though obese patients had a higher rate of > 50% pancreatic gland necrosis (27% versus 19%, p = 0.02). The rates of infected necrosis and organ failure were higher among obese patients. Percutaneous drainage was more common in obese patients. Time to first necrosis intervention was earlier with increasing BMI. NP disease duration was longer in obese patients. The overall mortality rate of non-obese and obese patients did not differ. However, mortality rate increased with increasing BMI.

CONCLUSION

Necrotizing pancreatitis in obese patients is characterized by a prolonged disease course, a higher risk of organ failure, infected necrosis, and the need for early necrosis-related intervention. Mortality increases with increasing BMI.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

Pancreatic colonization of fungi in the development of severe acute pancreatitis

Acute pancreatitis is a common emergent disorder, a significant population of which develops the life-threatening condition, called severe acute pancreatitis (SAP). It is generally accepted that bacterial infection is associated with the development and persistence of SAP. In addition to bacterial infection, recent clinical studies disclosed a high incidence of fungal infection in patients with SAP. Moreover, SAP patients with fungal infection exhibit a higher mortality rate than those without infection. Although these clinical studies support pathogenic roles played by fungal infection in SAP, beneficial effects of prophylactic anti-fungal therapy on SAP have not been proved. Here we summarize recent clinical findings as to the relationship between fungal infection and the development of SAP. In addition, we discuss molecular mechanisms accounting for the development of SAP in the presence of fungal infection.

MiR155 Disrupts the Intestinal Barrier by Inducing Intestinal Inflammation and Altering the Intestinal Microecology in Severe Acute Pancreatitis

BACKGROUND

Intestinal dysfunction is a common complication of acute pancreatitis. MiR155 may be involved in the occurrence and development of intestinal dysfunction mediated by acute pancreatitis, but the specific mechanism is not clear.

AIMS

To investigate the effect of miR155 on severe acute pancreatitis (SAP)-associated intestinal dysfunction and its possible mechanism in a mice model.

METHODS

In this study, SAP mice model was induced by intraperitoneal injection of caerulein and LPS in combination. Adeno-associated virus (AAV) was given by tail vein injection before the SAP model. The pancreatic and intestinal histopathology changes were analyzed. Cecal tissue was collected for 16S rRNA Gene Sequencing. Intestinal barrier proteins ZO-1 and E-cad were measured by Immunohistochemistry Staining and Western Blot, respectively. Intestinal tissue miR155 and inflammatory factors TNF-α, IL-1β, and IL-6 were detected by Q-PCR. The expression levels of protein associated with TNF-α and TLR4/MYD88 pathway in the intestinal were detected.

RESULTS

In miR155 overexpression SAP group, the levels of tissue inflammatory factor were significantly increased, intestinal barrier proteins were significantly decreased, and the injury of intestinal was aggravated. Bacterial 16S rRNA sequencing was performed, showing miR155 promotes gut microbiota dysbiosis. The levels of TNF-α, TLR4, and MYD88 in the intestinal were detected, suggesting that miR155 may regulate gut microbiota and activate the TLR4/MYD88 pathway, thereby affecting the release of inflammatory mediators and regulating SAP-related intestinal injury. After application of miR155-sponge, imbalance of intestinal flora and destruction of intestinal barrier-related proteins have been alleviated. The release of inflammatory mediators decreased, and the histopathology injury of intestinal was improved obviously.

CONCLUSION

MiR155 may play an important role in SAP-associated intestinal dysfunction. MiR155 can significantly alter the intestinal microecology, aggravated intestinal inflammation through TLR4/MYD88 pathway, and disrupts the intestinal barrier in SAP mice.

Effects of immediate or early oral feeding on acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

The timing of oral refeeding can affect length of stay (LOS) and recovery of acute pancreatitis (AP). However, the optimal timing for oral refeeding is still controversial for AP. This meta-analysis investigated the effects of immediate or early versus delayed oral feeding on mild and moderate AP, regardless of improvement in clinical signs or laboratory indicators.

METHODS

This systematic review and meta-analysis of randomized controlled trials (RCTs) based on data from Embase, Cochrane Library, PubMed, Web of science, and CBM before August 2021. Two researchers independently used Stata16 to extract and analyse study data. Random effect model was performed for meta-analysis to calculate the risk ratio (RR) and standardized mean difference (SMD).

RESULTS

8 RCTs were selected, including 748 patients with mild to moderate AP. Patients in IOR (Immediate or early Oral Refeeding) group had less costs [SMD -0.83, 95%CI (-1.17, -0.5), P < 0.001] and shorter LOS [SMD -1.01, 95%CI (-1.17, -0.85), P < 0.001] than the DOR (Delayed Oral Refeeding) group patients. However, there was no difference in mortality [RR 0.54, 95%CI (0.11, 2.62), P = 0.44], pain relapse rate [RR 0.58, 95%CI (0.25, 1.35), P = 0.27], feeding intolerance rate [RR 0.61, 95%CI (0.28, 1.3), P = 0.2], AP progression rate [RR 0.21, 95%CI (0.04, 1.07), P = 0.06] and overall complications rate [RR 0.41, 95%CI (0.17, 1.01), P = 0.05] between the IOR and DOR groups.

CONCLUSIONS

Limited data suggest that IOR could reduce LOS and costs without increasing adverse events in mild to moderate AP.

Gut Dysbiosis in Pancreatic Diseases: A Causative Factor and a Novel Therapeutic Target

Pancreatic-related disorders such as pancreatitis, pancreatic cancer, and type 1 diabetes mellitus (T1DM) impose a substantial challenge to human health and wellbeing. Even though our understanding of the initiation and progression of pancreatic diseases has broadened over time, no effective therapeutics is yet available for these disorders. Mounting evidence suggests that gut dysbiosis is closely related to human health and disease, and pancreatic diseases are no exception. Now much effort is under way to explore the correlation and eventually potential causation between the gut microbiome and the course of pancreatic diseases, as well as to develop novel preventive and/or therapeutic strategies of targeted microbiome modulation by probiotics, prebiotics, synbiotics, postbiotics, and fecal microbiota transplantation (FMT) for these multifactorial disorders. Attempts to dissect the intestinal microbial landscape and its metabolic profile might enable deep insight into a holistic picture of these complex conditions. This article aims to review the subtle yet intimate nexus loop between the gut microbiome and pancreatic diseases, with a particular focus on current evidence supporting the feasibility of preventing and controlling pancreatic diseases via microbiome-based therapeutics and therapies.

Recent Advances in Understanding the Structure and Function of the Human Microbiome

Trillions of microbes live within our bodies in a deep symbiotic relationship. Microbial populations vary across body sites, driven by differences in the environment, immunological factors, and interactions between microbial species. Major advances in genome sequencing enable a better understanding of microbiome composition. However, most of the microbial taxa and species of the human microbiome are still unknown. Without revealing the identity of these microbes as a first step, we cannot appreciate their role in human health and diseases. A shift in the microbial balance, termed dysbiosis, is linked to a broad range of diseases from simple colitis and indigestion to cancer and dementia. The last decade has witnessed an explosion in microbiome research that led to a better understanding of the microbiome structure and function. This understanding leads to potential opportunities to develop next-generation microbiome-based drugs and diagnostic biomarkers. However, our understanding is limited given the highly personalized nature of the microbiome and its complex and multidirectional interactions with the host. In this review, we discuss: (1) our current knowledge of microbiome structure and factors that shape the microbial composition, (2) recent associations between microbiome dysbiosis and diseases, and (3) opportunities of new microbiome-based therapeutics. We analyze common themes, promises, gaps, and challenges of the microbiome research.

Clostridioides difficile Infection Is Associated with Adverse Outcomes among Hospitalized Pediatric Patients with Acute Pancreatitis

PURPOSE

Studies in adults have shown an increasing incidence of Clostridioides difficile infection (CDI) in patients hospitalized with acute pancreatitis (AP). There is lack of epidemiological data on CDI and its impact on hospitalized pediatric patients with AP.

METHODS

We analyzed the National Inpatient Sample and Kids' Inpatient Database between the years 2003 and 2016 and included all patients (age <21 years) with a primary diagnosis of AP using specific International Classification of Diseases codes. We compared clinical outcomes between children with CDI and those without CDI. Our primary outcome was severe AP and secondary outcomes included length of stay and hospital charges.

RESULTS

A total of 123,240 hospitalizations related to AP were analyzed and CDI was noted in 0.6% of the hospital. The prevalence rate of CDI doubled from 0.4% (2003) to 0.8% (2016), p=0.03. AP patients with CDI had increased comorbidities, and also underwent more invasive surgical procedures, p<0.05. AP patients with CDI had a higher in-hospital mortality rate and increased prevalence of severe AP, p<0.001. Multivariate regression models showed that CDI was associated with 2.4 times (confidence interval [CI]: 1.91 to 3.01, p<0.001) increased odds of severe AP. CDI patients had 7.24 (CI: 6.81 to 7.67, p<0.001) additional hospital days while incurring $59,032 (CI: 54,050 to 64,014, p<0.001) additional hospitalization charges.

CONCLUSION

CDI in pediatric patients with AP is associated with adverse clinical outcomes and increased healthcare resource utilization. Further studies are needed to elucidate this association to prevent the development of CDI and to improve outcomes.

Amelioration of Alzheimer's Disease by Gut-Pancreas-Liver-Brain Interaction in an App Knock-In Mouse Model

In this study, we observed disease progression, changes in the gut microbiota, and interactions among the brain, liver, pancreas, and intestine in a mouse model of Alzheimer's disease (AD), in addition to attempting to inhibit disease progression through the dietary supplementation of L-arginine and limonoids. Wild-type mice (WC) and AD mice were fed a normal diet (AC), a diet supplemented with L-arginine and limonoids (ALA), or a diet containing only limonoids (AL) for 12-64 weeks. The normal diet-fed WC and AC mice showed a decrease in the diversity of the gut microbiota, with an increase in the Firmicutes/Bacteroidetes ratio, and bacterial translocation. Considerable bacterial translocation to the pancreas and intense inflammation of the pancreas, liver, brain, and intestinal tissues were observed in the AC mice from alterations in the gut microbiota. The ALA diet or AL diet-fed mice showed increased diversity of the bacterial flora and suppressed oxidative stress and inflammatory responses in hepatocytes and pancreatic cells, bacterial translocation, and neurodegeneration of the brain. These findings suggest that L-arginine and limonoids help in maintaining the homeostasis of the gut microbiota, pancreas, liver, brain, and gut in AD mice.

The Role of Gut Microbiota and Genetic Susceptibility in the Pathogenesis of Pancreatitis

Pancreatitis is one of the most common inflammatory diseases of the pancreas caused by autodigestion induced by excessive premature protease activation. However, recognition of novel pathophysiological mechanisms remains a still challenge. Both genetic and environmental factors contribute to the pathogenesis of pancreatitis, and the gut microbiota is a potential source of an environmental effect. In recent years, several new frontiers in gut microbiota and genetic risk assessment research have emerged and improved the understanding of the disease. These investigations showed that the disease progression of pancreatitis could be regulated by the gut microbiome, either through a translocation influence or in a host immune response manner. Meanwhile, the onset of the disease is also associated with the heritage of a pathogenic mutation, and the disease progression could be modified by genetic risk factors. In this review, we focused on the recent advances in the role of gut microbiota in the pathogenesis of pancreatitis, and the genetic susceptibility in pancreatitis.

Mesenteric Lymph Duct Ligation Alleviates Acute Lung Injury Caused by Severe Acute Pancreatitis Through Inhibition of High Mobility Group Box 1-Induced Inflammation in Rats

BACKGROUND

Acute lung injury (ALI) is the most common complication and one of the leading causes of mortality of severe acute pancreatitis (SAP). Nevertheless, no effective therapeutic schemes are presently available.

AIMS

To investigate the effect and potential mechanism of mesenteric lymph duct ligation (MLDL) on experimental SAP-induced ALI.

METHODS

Immediately following MLDL, rats were subjected to SAP by retrograde injection of 5% sodium taurocholate into the biliopancreatic duct. At 24 h after modeling, tissues were collected for morphological examination. The levels of TNF-α, IL-6, intercellular adhesion molecule-1 (ICAM1), diamine oxidase (DAO), and D-lactic acid (D-LA) in serum, and the myeloperoxidase (MPO) activity in lung tissues were determined. Moreover, the expressions of high mobility group box 1 (HMGB1), receptor of advanced glycation endproducts (RAGE), and NF-κB p65 at the mRNA and protein levels in lung tissues, and the expressions of HMGB1, RAGE, and TNF-α at the mRNA level in intestinal lymphoid tissues were evaluated.

RESULTS

MLDL significantly attenuated the histological injury of the pancreas and lung and reduced the production of TNF-α, IL-6, and ICAM1. Besides, MLDL repressed the activity of MPO in the lung. However, the levels of serum DAO and D-LA were decreased without obvious morphological improvement in intestinal injury. Moreover, MLDL apparently reduced the up-regulation of HMGB1, RAGE, and NF-κB p65 in lung tissues, as well as the expressions of HMGB1, RAGE, and TNF-α in intestinal lymphoid tissues.

CONCLUSIONS

Mesenteric lymph was a source of harmful factors leading to SAP-ALI. MLDL could alleviate SAP-ALI probably by inhibiting HMGB1-induced production of inflammation factors.

Interaction Between Commensal Bacteria, Immune Response and the Intestinal Barrier in Inflammatory Bowel Disease

In inflammatory bowel disease (IBD), intestinal mucosa cell and intestinal epithelial cell are severely damaged, and then their susceptibility to bacteria increases, so many commensal bacteria become pathogenic. The pathogenic commensal bacteria can stimulate a series of compensatory immune responses in the intestine. However, the immune response prevents the intestinal tract from restoring homeostasis, which in turn produces an indispensable inflammatory response. On the contrary, in IBD, the fierce inflammatory response contributes to the development of IBD. However, the effect of commensal bacteria on inflammation in IBD has not been clearly studied. Therefore, we further summarize the changes brought about by the changes of commensal bacteria to the inflammation of the intestines and their mutual influence. This article reviews the protective mechanism of commensal bacteria in healthy people and the mechanism of commensal bacteria and immune response to the destruction of the intestinal barrier when IBD occurs. The treatment and prevention of IBD are also briefly summarized.

Spatioregional assessment of the gut microbiota in experimental necrotizing pancreatitis

BACKGROUND

Infectious complications following experimental pancreatitis involve major disruptions in the gut microbiota. The aim of this study was to characterize this disruption by examining the spatioregional distribution in microbial community structure and function following experimental pancreatitis associated with pancreatic infection.

METHODS

Mice were subjected to infusion of the pancreatic duct with either taurocholate to induce necrotizing pancreatitis or normal saline (control group). The spatial (lumen versus mucosa) and regional composition and function of the microbiota from the duodenum, ileum, caecum, colon, pancreas and blood were evaluated using 16S rRNA gene amplicon sequencing.

RESULTS

Mice that developed necrotizing pancreatitis demonstrated a decrease in microbial richness and significantly altered microbiota in distal parts of the gastrointestinal tract, compared with controls. Among the most differentially increased taxa were the mucus-degrading Akkermansia muciniphila, and there was a decrease of butyrate-producing bacteria following pancreatitis. Application of the SourceTracker tool to the generated metadata indicated that the duodenum was the most probable source of bacteria that subsequently infected pancreatic tissue in this model. The functional prediction annotation using pathway analyses indicated a diminished capacity of the caecal microbiota to metabolize carbohydrate, and fatty and amino acids.

DISCUSSION

The distal gut microbiota was significantly impacted in this model of experimental necrotizing pancreatitis. Data suggest that the duodenal microbiota might also play a role in bacterial translation and secondary infections.

Study protocol P-MAPS: microbiome as predictor of severity in acute pancreatitis-a prospective multicentre translational study

Background

Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients.

Methods

We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality.

Discussion

If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future.

Trial registration: ClinicalTrials.gov Identifier: NCT04777812

Trefoil factor-2, an early predictor for acute gastrointestinal injury in patients with acute pancreatitis

Acute gastrointestinal injury (AGI) is commonly present in patients with acute pancreatitis (AP). It is often difficult to predict gastrointestinal function in the early stage due to lack of reliable markers. We aimed to assess whether early plasma trefoil factor 2 (TFF-2) is a potential predictor for AGI.Fifty one patients were included for the onset of AP (from developing abdominal pain) within 72 hours in this prospective observational single-center study from January 2013 to July 2015. Among them 23 patients were classified as mild, 17 as moderately severe, and 11 as severe according to 2012 Atlanta classification. Plasma samples were collected only once at admission to the ICU. Twenty samples of healthy adults were also collected as control. The TFF-2 levels were determined by using a human TFF-2 enzyme-linked immunoassay. AGI grades from 1st to 7th day after admission were observed.The plasma TFF-2 levels among AP patients in early stage were significantly higher than healthy controls (766.41 ng/mL vs 94.37 ng/mL, P < .0001). The correlations between TFF-2 levels and AGI grades from 1st to 4th day after admission were positive (r = 0.47, 0.43, 0.42, 0.40 respectively, P < .05). As a predictor of acute gastrointestinal failure, plasma TFF-2 was superior to others: Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, procalcitonin, C-reactive protein, serum calcium. In addition, TFF-2 increased along with the severity of AP (r = 0.554, P < .0001) and associated with Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, C-reactive protein, serum calcium.The plasma TFF-2 levels were increased in patients in early stage of AP and correlated with AGI grades and disease severity in our study. TFF-2 might be a potential predictor for acute gastrointestinal failure in patients with AP.

Pretreatment with chitosan oligosaccharides attenuate experimental severe acute pancreatitis via inhibiting oxidative stress and modulating intestinal homeostasis

Severe acute pancreatitis (SAP) is a severe acute abdominal disease. Recent evidence shows that intestinal homeostasis is essential for the management of acute pancreatitis. Chitosan oligosaccharides (COS) possess antioxidant activity that are effective in treating various inflammatory diseases. In this study we explored the potential therapeutic effects of COS on SAP and underlying mechanisms. Mice were treated with COS (200 mg·kg-1·d-1, po) for 4 weeks, then SAP was induced in the mice by intraperitoneal injection of caerulein. We found that COS administration significantly alleviated the severity of SAP: the serum amylase and lipase levels as well as pancreatic myeloperoxidase activity were significantly reduced. COS administration suppressed the production of proinflammatory cytokines (TNF-α, IL-1β, CXCL2 and MCP1) in the pancreas and ileums. Moreover, COS administration decreased pancreatic inflammatory infiltration and oxidative stress in SAP mice, accompanied by activated Nrf2/HO-1 and inhibited TLR4/NF-κB and MAPK pathways. We further demonstrated that COS administration restored SAP-associated ileal damage and barrier dysfunction. In addition, gut microbiome analyses revealed that the beneficial effect of COS administration was associated with its ability to improve the pancreatitis-associated gut microbiota dysbiosis; in particular, probiotics Akkermansia were markedly increased, while pathogenic bacteria Escherichia-Shigella and Enterococcus were almost eliminated. The study demonstrates that COS administration remarkably attenuates SAP by reducing oxidative stress and restoring intestinal homeostasis, suggesting that COS might be a promising prebiotic agent for the treatment of SAP.