Obesity as a risk factor for severe acute pancreatitis patients

Retrospective analysis of surgical pancreatic necrosectomy outcomes in patients with and without obesity

BACKGROUND

Acute necrotizing pancreatitis is associated with high morbidity and mortality. This study aims to compare surgical necrosectomy outcomes in acute necrotizing pancreatitis between patients with and without obesity.

METHODS

A retrospective chart review was performed for all patients who underwent surgical necrosectomy via a minimally invasive approach or an open approach over a 10-year period at a large US healthcare system. Patients were divided into 2 groups: those with obesity (body mass index ≥30 kg/m2) and those without obesity (body mass index <30 kg/m2). The primary end point was the incidence of early complications or postoperative death within 30 and 90 days. The secondary end point was the incidence of long-term complications.

RESULTS

In total, 80 patients were included with 36 (45%) with obesity, and 44 (55%) without obesity. A total of 52 patients (65%) had an open approach and 28 (35%) had an minimally invasive approach. The average age was 54.79 ± 15.25 years, and the median follow-up time was 83.5 days (interquartile range, 40.25-149.75 days). The median body mass index of the patient group with obesity was 34.55 kg/m2 (interquartile range, 31.55-40.61), and that for the patient group without obesity was 25.97 kg/m2 (interquartile range, 23.22-28.35 kg/m2) (P ≤ .0001). Days from admission to surgical intervention was longer in obese patients but it was not statistically significant (44.50 [interquartile range, 12-88] vs 27 [interquartile range, 15-42.5], P = .831). 30 and 90-day complication rates and mortality were similar between the groups.

CONCLUSION

Operative outcomes of pancreatic necrosectomy in patients with obesity appears to be comparable with patients without obesity. Surgical pancreatic necrosectomy can be performed safely, effectively, and in a similar time frame regardless of the presence of obesity.

Low skeletal muscle quality extracted from CT is associated with poor outcomes in severe acute pancreatitis patients

PURPOSE

To evaluate the association between body composition parameters derived from computed tomography (CT) scans and clinical outcomes in patients with severe acute pancreatitis (AP).

METHODS

Patients who have been diagnosed AP with a CT scan at ICU admission were included. Body composition parameters were measured on a single slice at L2-3 of the unenhanced CT scans. The intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), skeletal muscle area (SMA) and skeletal muscle density (SMD) were assessed using HUs by image analysis software. Univariable and multivariable analyses were performed to analyze the association between body composition parameters and clinical outcomes including all-cause mortality or prolonged ICU stay. The area under the curve (AUC) of a receiver operating characteristic curve was used to explore the predictive value of the body composition on treatment clinical outcomes.

RESULTS

A total of 158 patients were included. The IMAT (8.3 cm2 vs 6.0 cm2, P = 0.001) and VAT (190.3 cm2 vs 143.7 cm2, P < 0.001) were significantly higher in the severe AP group than in the moderately severe group, but were notassociatedwithoutcomes. For 1 HU of SMD increased, the risk of poor clinical outcomes decresed 11 % (adjusted OR 0.892, 95 %CI 0.806-0.987, P = 0.026), while an SMD below the median value (32.1 HU for males and 28.5 HU for females) was independently associated with worse outcomes in the multivariable analysis (adjusted OR 8.868, 95 % CI 2.146-36.650, P = 0.003). The SMD had a good predictive ability for clinical outcomes, AUC was 0.824 (95 % CI, 0.715-0.933) for males and 0.803 (95 % CI, 0.639-0.967) for females.

CONCLUSION

Low SMD was associated with poor outcomes in patients with severe and moderately severe AP and might be used as a novel marker to predict outcomes in patients suffering from severe and moderately severe AP.

Birth weight, childhood obesity, adulthood obesity and body composition, and gastrointestinal diseases: a Mendelian randomization study

OBJECTIVE

This Mendelian randomization study aimed to investigate the associations of birth weight, childhood BMI, and adulthood BMI, waist-hip ratio, and body composition with the risk of 24 gastrointestinal diseases.

METHODS

Independent genetic instruments associated with the exposures at the genome-wide significance level (p < 5 × 10-8 ) were selected from corresponding large-scale genome-wide association studies. Summary-level data for gastrointestinal diseases were obtained from the UK Biobank, the FinnGen study, and large consortia of European ancestry.

RESULTS

Genetically predicted higher levels of birth weight were associated with a lower risk of gastroesophageal reflux. Genetically predicted higher childhood BMI was associated with an increased risk of duodenal ulcer, nonalcoholic fatty liver disease, and cholelithiasis. However, the associations did not persist after adjusting for genetically predicted adulthood BMI. Genetically predicted higher adulthood BMI and waist-hip ratio were associated with 19 and 17 gastrointestinal diseases, respectively. Genetically predicted greater visceral adiposity was associated with an increased risk of 17 gastrointestinal diseases. There were no strong associations among genetically predicted whole-body fat and fat-free mass indices with gastrointestinal diseases.

CONCLUSIONS

This study suggests that greater adulthood adiposity, measured as either BMI, waist-hip ratio, or visceral adipose tissue, is causally associated with an increased risk of a broad range of gastrointestinal diseases in the European population.

High risk of complications and acute-on-chronic liver failure in cirrhosis patients with acute pancreatitis

BACKGROUND & AIMS

Acute pancreatitis (AP) is a frequent indication for hospitalization and may present with varying degrees of severity. AP often coincides with hepatic disease, yet the impact of liver cirrhosis (LC) on the course of AP is uncertain, and early identification of patients at risk for complications remains challenging. We aimed to assess the impact of LC on the development of pancreatic and extra-pancreatic complications of AP, and to identify predictors of adverse outcomes in cirrhotic patients.

METHODS

All adult patients with LC and AP (LC-AP, n = 52) admitted to our institution between 01/2011-03/2020 were subjected to a 1:2 matched-pair analysis with patients with AP but without LC (NLC-AP, n = 104).

RESULTS

At hospital admission, Glasgow-Imrie and Ranson scores as well as markers of systemic inflammation were comparable in LC-AP and NLC-AP patients, and both groups had similar rates of necrotizing AP. Infectious complications were more prevalent, and medical interventions were performed more often and with higher complication rates in LC-AP patients. While only 12.5% of NLC-AP patients developed organ failures, 48% of LC-AP patients developed single (7.7%) or multiple organ failure (40.4%), resulting in 44% of LC-AP patients with acute-on-chronic liver failure (ACLF). Patients with overt portal hypertension were particularly prone for decompensation. Mortality was higher among LC-AP compared to NLC-AP patients (6-month mortality 25% vs. 1.9%, p < 0.001), and SOFA and MELD scores at admission most accurately predicted outcomes in LC-AP.

CONCLUSION

Among AP patients, concomitant cirrhosis substantially increases the risk for infections, periprocedural complications, multiorgan failure and death.

Progress in research of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare and severe complication of pregnancy, which is characterized by rapid onset, rapid progression, many complications, and high mortality. According to previous studies, the incidence of APIP is about 1/10000-1/1000 and increases with gestational age. Due to the differences in genetic background and dietary habits between Asian and European populations, the incidence of APIP in China is as high as 1.14‰-2.27‰, significantly higher than that in Western countries. The lack of specific clinical symptoms of APIP often leads to misdiagnosis or missed diagnosis, which greatly increases the difficulty of diagnosis and treatment. Despite the deepening of the research on APIP, its pathogenesis is still unclear. This paper will give a systematical review of APIP.

The course of acute pancreatitis in patients with different BMI groups

OBJECTIVES

To evaluate the risk factors, Atlanta severity score, Balthazar-CTSI score, and disease course in patients of varying weight with acute pancreatitis (AP).

METHODS

A retrospective evaluation was made of normal weight (NW), overweight (OW), and obese (OB) patients (n:1134) with respect to demographic findings, diabetes (DM)/hypertension, smoking/alcohol use, etiologies, laboratory findings, Balthazar/Atlanta severity scores, and disease outcomes. After consistency and associations among the BMI, Balthazar, and Atlanta groups were evaluated, combined effects of risk factors on mortality, hospital and ICU stays were re-examined statistically.

RESULTS

In the OB group, mean age (p < 0.001), female gender (p < 0.001), increased BUN(p < 0.027) and Hct (p = 0.039), DM(p < 0.024), and mortality (p < 0.011) were statistically significant. In the non-NW groups, the rates of complications (40.6%/38.6%), mortality (3.7%/4.9%), interventional procedures (36%/39%), and length of hospital stay (11.6%/9.8%) were increased. Obesity constituted 23.7% of severe AP(SAP) and 50% of mortality. There was no significant relationship between Atlanta and Balthazar groups and BMI, nor between Balthazar and moderate AP (MSAP) to SAP. Old age (p = 0.000), male sex (p = 0.05), obesity (p = 0.046), alcohol (p = 0.014), low Hct (p = 0.044), high CRP (p = 0.024), MSAP/SAP (p = 0.02/(p < 0.001), and any complications (p < 0.001) increased the mortality risk. Female gender (p = 0.024), smoking (p = 0.021), hypertriglyceridemia (p = 0.047), idiopathic etiology (p = 0.023), and MSAP/SAP (p < 0.001) associations increased ICU admission. Co-occurrences of higher Balthazar score (p < 0.001), MSAP/SAP (p < 0.001), all kinds of complications (p < 0.001), and recurrence (p = 0.040) increased the hospital stay (≥11 days).

CONCLUSIONS

Although complications, mortality, longer hospitalization, and interventional procedures were observed more in the overweight and obese, successful prediction of Atlanta severity and Balthazar-CTSI scores based on BMI does not appear to be accurate. OB carries an increased risk for morbidity and mortality. The combined effects of risk factors increased mortality, longer hospital stays, and ICU admission.

Effect of abdominal fat distribution on severity of acute pancreatitis

Aim of the study

Obesity is a well-determined risk factor for acute pancreatitis. Increased visceral fat has been shown to increase the proinflammatory environment experienced by patients. In this study, we aimed to research the correlation between abdominal fat distribution parameters measured with computed tomography (CT) and severity of acute pancreatitis (AP).

Material and methods

The study included patients monitored due to AP in the internal medicine clinic of GOP Education and Research Hospital from January 2015 to December 2018. The Acute Physiology and Chronic Health Evaluation (APACHE) score, the Imrie score and the Bedside Index of Severity in Acute Pancreatitis (BISAP) scores were calculated. Advanced image processing analysis software (INFINIT Xelis, v 1.0.6.3) was used to calculate individual abdominal fat distribution parameters from CT screening with division of abdominal tissues. Measurements were performed from –50 to –250 Hounsfield units (HU) between vertebrae L2-L3.

Results

When mild and moderate AP groups were compared, there were statistically significant differences in duration of hospital stay and scoring (APACHE, Imrie and BISAP) (p < 0.001), while there were no significant differences in abdominal fat distribution parameters (p > 0.05). There was no significant correlation of visceral and subcutaneous fat volumes with development of systemic complications, while a significant correlation was identified for visceral to total fat tissue area ratio (VTR) with local complications (p < 0.001). Pearson correlation analysis found no correlations of mortality and pancreatitis severity with visceral (VFA) and subcutaneous fat area (SFA) (p > 0.05). Positive correlations were identified for VFA with Imrie, BISAP and APACHE scores (p < 0.01), and positive correlations were identified for visceral adipose tissue (VAT) with visceral to subcutaneous fat ratio (VSR) and APACHE scores (r = 0.256 and 0.252, respectively, p < 0.001). Positive correlations were identified for VTR and VSR ratios with BISAP scores (r = 0.266 and r = 0.277, respectively, p < 0.001).

Conclusions

In patients with AP diagnosis and abdominal CT scans, increased VFA and VTR ratio were found to be associated with increased AP clinical scores with no significant correlation identified in terms of local/systemic complication development. Our study shows that VFA is linked to AP clinical scoring systems and should be included in AP predictive scoring systems.

Declines and pronounced regional disparities in meperidine use in the United States

There have been increasing concerns about adverse effects and drug interactions with meperidine. The goal of this study was to characterize meperidine use in the United States. Meperidine distribution data were obtained from the Drug Enforcement Administration's Automated of Reports and Consolidated Orders System. The Medicare Part D Prescriber Public Use File was utilized to capture overall trends in national prescriptions in this observational report. Nationally, meperidine distribution decreased by 94.6% from 2001 to 2019. In 2019, Arkansas, Alabama, Oklahoma, and Mississippi saw significantly greater distribution when compared with the US state average of 9.27 mg per 10 persons (SD = 6.82). Meperidine distribution showed an 18-fold difference between the highest state (Arkansas = 36.8 mg) and lowest state (Minnesota = 2.1 mg). Five of the six states with the lowest distribution were in the Northeast. Meperidine distribution per state was correlated with the prevalence of adult obesity (r(48) = +0.48, p < .001). Family medicine and internal medicine physicians accounted for 28.9% and 20.5%, respectively, of meperidine total daily supply (TDS) in 2017. Interventional pain management (5.66) and pain management (3.48) physicians accounted for the longest TDS per provider. The use of meperidine declined over the last two decades. Meperidine varied by geographic region with south-central states, and those with more obesity, showing greater distribution. Primary care doctors continue to account for the majority of meperidine daily supply. Increasing knowledge of meperidine's undesirable adverse effects like seizures and serious drug-drug interactions is likely responsible for these pronounced reductions.

Ranson score to stratify severity in Acute Pancreatitis remains valid - Old is gold

Introduction: Acute pancreatitis (AP) is a common gastrointestinal disease with a wide spectrum of severity and morbidity. Developed in 1974, the Ranson score was the first scoring system to prognosticate AP. Over the past decades, while the Ranson score remains widely used, it was identified to have certain limitations, such as having low predictive power. It has also been criticized for its 48-hour requirement for computation of the final score, which has been argued to potentially delay management. With advancements in our understanding of AP, is the Ranson score still relevant as an effective prognostication system for AP?Areas covered: This review summarizes the available evidence comparing Ranson score with other conventional and novel scoring systems, in terms of prognostic accuracy, benefits, limitations and clinical applicability. It also evaluates the effectiveness of Ranson score with regard to the Revised Atlanta Classification.Expert opinion: The Ranson score consistently exhibits comparable prognostic accuracy to other newer scoring systems, and the 48-hour timeframe for computing the full Ranson score is an inherent strength, not a weakness. These aspects, coupled with relative ease of use, practicality and universality of the score, advocate for the continued relevance of the Ranson score in modern clinical practice.

Astaxanthin Inhibits Interleukin-6 Expression in Cerulein/Resistin-Stimulated Pancreatic Acinar Cells

Acute pancreatitis is a common clinical condition with increasing the proinflammatory mediators, including interleukin-6 (IL-6). Obesity is a negative prognostic factor in acute pancreatitis. Obese patients with acute pancreatitis have a higher systemic inflammatory response rate. Levels of serum resistin, an adipocytokine secreted by fat tissues, increase with obesity. Cerulein, a cholecystokinin analog, induces calcium (Ca²⁺) overload, oxidative stress, and IL-6 expression in pancreatic acinar cells, which are hallmarks of acute pancreatitis. A recent study showed that resistin aggravates the expression of inflammatory cytokines in cerulein-stimulated pancreatic acinar cells. We aimed to investigate whether resistin amplifies cerulein-induced IL-6 expression and whether astaxanthin (ASX), an antioxidant carotenoid with anti-inflammatory properties, inhibits ceruelin/resistin-induced IL-6 expression in pancreatic acinar AR42J cells. We found that resistin enhanced intracellular Ca²⁺ levels, NADPH oxidase activity, intracellular reactive oxygen species (ROS) production, NF-κB activity, and IL-6 expression in cerulein-stimulated AR42J cells, which were inhibited by ASX in a dose-dependent manner. The calcium chelator BAPTA-AM inhibited cerulein/resistin-induced NADPH oxidase activation and ROS production. Antioxidant N-acetyl cysteine (NAC) and ML171, a specific NADPH oxidase 1 inhibitor, suppressed cerulein/resistin-induced ROS production, NF-κB activation, and IL-6 expression. In conclusion, ASX inhibits IL-6 expression, by reducing Ca²⁺ overload, NADPH oxidase-mediated ROS production, and NF-κB activity in cerulein/resistin-stimulated pancreatic acinar cells. Consumption of ASX-rich foods could be beneficial for preventing or delaying the incidence of obesity-associated acute pancreatitis.

Decreased infiltration of adipose tissue macrophages and amplified inflammation of adipose tissue in obese mice with severe acute pancreatitis

OBJECTIVE

Macrophages are involved in obesity-associated inflammation and severe acute pancreatitis (SAP) development. However, the role of adipose tissue macrophages (ATMs) in obesity-related SAP has not been fully elucidated. We investigated the relationship between ATMs and inflammatory responses in SAP model mice fed a high-fat diet (HFD).

METHODS

SAP was induced in animal models via intraperitoneal injections of caerulein and lipopolysaccharide (LPS). SAP severity was evaluated, both morphologically and biochemically, and macrophage infiltration in the pancreas and epididymal adipose tissue was measured. We also analyzed apoptosis levels, polarization of the ATMs, and expression of inflammatory mediators in epididymal adipose tissue.

RESULTS

Obesity increased disease severity in SAP animals. Increased macrophage infiltration in the pancreas induced by SAP was found in both normal diet (ND)- and HFD-fed mice. Total ATM infiltration in epididymal adipose tissue was elevated by HFD, while a significant decrease in infiltration was observed in both the ND + SAP and HFD + SAP groups. The apoptosis levels of ATMs were reduced in the HFD group, but were markedly enhanced in both the ND + SAP and HFD + SAP groups compared to their respective control groups. Higher levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and monocyte chemoattractant protein-1 (MCP-1) were observed in the HFD + SAP than in the ND + SAP group. Increased proportion of M1 type ATMs was induced by both HFD and SAP.

CONCLUSIONS

Total ATM infiltration was decreased in epididymal adipose tissue of SAP animals. ATM polarization to the M1 type resulted in an amplified inflammatory response in obese mice with SAP.

Adipose saturation reduces lipotoxic systemic inflammation and explains the obesity paradox

Obesity sometimes seems protective in disease. This obesity paradox is predominantly described in reports from the Western Hemisphere during acute illnesses. Since adipose triglyceride composition corresponds to long-term dietary patterns, we performed a meta-analysis modeling the effect of obesity on severity of acute pancreatitis, in the context of dietary patterns of the countries from which the studies originated. Increased severity was noted in leaner populations with a higher proportion of unsaturated fat intake. In mice, greater hydrolysis of unsaturated visceral triglyceride caused worse organ failure during pancreatitis, even when the mice were leaner than those having saturated triglyceride. Saturation interfered with triglyceride's interaction and lipolysis by pancreatic triglyceride lipase, which mediates organ failure. Unsaturation increased fatty acid monomers in vivo and aqueous media, resulting in greater lipotoxic cellular responses and organ failure. Therefore, visceral triglyceride saturation reduces the ensuing lipotoxicity despite higher adiposity, thus explaining the obesity paradox.

Class III obesity rather than metabolic syndrome impacts clinical outcomes of acute pancreatitis: A propensity score weighted analysis

OBJECTIVES

The incidence rates of acute pancreatitis (AP) and the prevalence of class III obesity, and metabolic syndrome (MetS) are increasing in the US. Since class III obesity was associated with adverse clinical outcomes of AP, we sought to understand if the presence of metabolic comorbidities collectively recognized, as MetS were associated with worse clinical outcomes and increased health-care utilization.

METHODS

The Nationwide Readmissions Database (NRD) (2010-2014) was reviewed to identify all adult subjects with a principal discharge diagnosis of AP. Inpatient mortality, severe AP (SAP), and 30-day readmissions were the primary outcomes analyzed. Propensity score weighted analyses were used to compare AP subjects with and without MetS and were further stratified by class III obesity status.

RESULTS

MetS was associated with 12.91% (139,165/1,078,183) of all admissions with AP. Propensity score weighted analyses showed that MetS was associated with an increased proportion of SAP (OR 1.21, 95% CI 1.17, 1.25), but decreased mortality (OR 0.62, 95% CI 0.54, 0.70) and 30-day readmissions (OR 0.86, 95% CI 0.83, 0.89). Propensity score weighted analyses also revealed that class III obesity was independently associated with increased mortality in AP subjects with (OR 1.92, 95% CI 1.41, 2.61) and without MetS (OR 1.55, 95% CI 1.26, 1.92), and increased SAP in subjects with and without MetS.

CONCLUSIONS

Class III obesity appears to be the primary factor associated with adverse clinical outcomes in subjects with MetS admitted with AP. This has significant implications for patient management and future research targeting AP.

Relationships between Metabolic Comorbidities and Occurrence, Severity, and Outcomes in Patients with Acute Pancreatitis: A Narrative Review

Background. The population of patients with acute pancreatitis treated by the staff at our department of gastroenterology includes those with mild and self-limited disease ranging to those with severe and fatal disease. Early diagnosis and accurate prediction of the severity and outcome of this disease, which is commonly seen by our department, is important for a successful outcome. Metabolic comorbidities (e.g., diabetes mellitus, fatty liver, obesity, and metabolic syndrome) are relevant to the severity and progression of many diseases. The objective of this review was to examine clinical relationships between metabolic comorbidities and occurrence, severity, and outcome of acute pancreatitis.

The association between obesity and outcomes in acute pancreatitis: an individual patient data meta-analysis

OBJECTIVES

There are data to suggest that obesity is associated with local and systemic complications as well as mortality in acute pancreatitis (AP). Cohort studies to date, however, have shown conflicting results from mostly unadjusted analyses. Therefore, we performed an individual patient data meta-analysis with the primary aim to investigate the association between obesity and mortality in AP. Our secondary aim was to investigate the association between obesity and necrosis, organ failure, multiple organ failure, and invasive intervention.

PATIENTS AND METHODS

We systematically searched four electronic databases for prospective studies on obesity and outcomes in AP. Researchers of eligible studies were invited to share individual patient data using a standardized data collection form. All end points were investigated with a one-stage mixed effects Poisson model with random intercepts and forced entry of relevant confounders.

RESULTS

We included five databases with 1302 patients, of whom 418 (32%) were obese. In total, 466 (36%) patients had necrosis, 328 (25%) had organ failure, 188 (14%) had multiple organ failure, 210 (16%) had an intervention, and 84 (7%) patients died. We found no significant association between obesity and mortality [relative risk (RR) 1.40, 95% confidence interval (CI): 0.89-2.20], necrosis (RR: 1.08, 95% CI: 0.90-1.31) or invasive intervention (RR: 1.10, 95% CI: 0.83-1.47) after adjustment for confounders. However, obesity was independently associated with the development of organ failure (RR: 1.38, 95% CI: 1.11-1.73) and multiple organ failure (RR: 1.81, 95% CI: 1.35-2.42).

CONCLUSION

Obesity is independently associated with the development of organ failure and multiple organ failure in AP. However, there is no association between obesity and mortality, necrosis, and an intervention.

Body-mass index correlates with severity and mortality in acute pancreatitis: A meta-analysis

BACKGROUND

Obesity rates have increased sharply in recent decades. As there is a growing number of cases in which acute pancreatitis (AP) is accompanied by obesity, we found it clinically relevant to investigate how body-mass index (BMI) affects the outcome of the disease.

AIM

To quantify the association between subgroups of BMI and the severity and mortality of AP.

METHODS

A meta-analysis was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols. Three databases (PubMed, EMBASE and the Cochrane Library) were searched for articles containing data on BMI, disease severity and mortality rate for AP. English-language studies from inception to 19 June 2017 were checked against our predetermined eligibility criteria. The included articles reported all AP cases with no restriction on the etiology of the disease. Only studies that classified AP cases according to the Atlanta Criteria were involved in the severity analyses. Odds ratios (OR) and mean differences (MD) were pooled using the random effects model with the DerSimonian-Laird estimation and displayed on forest plots. The meta-analysis was registered in PROSPERO under number CRD42017077890.

RESULTS

A total of 19 articles were included in our meta-analysis containing data on 9997 patients. As regards severity, a subgroup analysis showed a direct association between AP severity and BMI. BMI < 18.5 had no significant effect on severity; however, BMI > 25 had an almost three-fold increased risk for severe AP in comparison to normal BMI (OR = 2.87, 95%CI: 1.90-4.35, P < 0 .001). Importantly, the mean BMI of patients with severe AP is higher than that of the non-severe group (MD = 1.79, 95%CI: 0.89-2.70, P < 0.001). As regards mortality, death rates among AP patients are the highest in the underweight and obese subgroups. A BMI < 18.5 carries an almost two-fold increase in risk of mortality compared to normal BMI (OR = 1.82, 95%CI: 1.32-2.50, P < 0.001). However, the chance of mortality is almost equal in the normal BMI and BMI 25-30 subgroups. A BMI > 30 results in a three times higher risk of mortality in comparison to a BMI < 30 (OR = 2.89, 95%CI: 1.10-7.36, P = 0.026).

CONCLUSION

Our findings confirm that a BMI above 25 increases the risk of severe AP, while a BMI > 30 raises the risk of mortality. A BMI < 18.5 carries an almost two times higher risk of mortality in AP.

Rapid Progression of Acute Pancreatitis to Acute Recurrent Pancreatitis in Children

OBJECTIVE

Research is lacking on the natural history of acute pancreatitis (AP) progression to acute recurrent pancreatitis (ARP). The aim of this project was to study the progression from AP to ARP among pediatric patients with pancreatitis to better understand the presentation and natural history of pancreatitis.

METHODS

Patients presenting with AP were included in a prospective database in Research Electronic Data Capture. We enrolled 115 patients with AP from March 2013 to November 2016. Physicians completed surveys regarding clinical data for patients with first attack of AP. Patients were followed prospectively, with data on progression entered when patients presented with ARP.

RESULTS

The most common etiologies for the first attack of AP were idiopathic (31%), toxic/drug-related (23%), and biliary/gallstone (18%). Twenty of the 115 patients (17%) developed ARP during the follow-up period. Seventy percent (14/20) of patients with ARP progressed from AP to ARP within 5 months from first diagnosis. A comparison of patients who rapidly progressed to ARP within 3 months (n = 12) to those followed for >3 months without progression in 3 months (n = 97) revealed associations with a higher weight percentile for age (P = 0.045), male sex (P = 0.03), and presence of pancreatic necrosis during first AP attack (P = 0.004). Progression to ARP significantly differed by etiology group with genetics having the highest risk for ARP progression over time and patients with gallstone/biliary, viral/systemic, and obstructive (nongallstone) having the lowest risk for ARP progression over time (P = 0.02).

CONCLUSIONS

Most patients who progressed from AP to ARP progressed within 5 months. The presence of a higher weight percentile for age, male sex, and pancreatic necrosis during the first AP attack are associated with rapid progression to ARP.

Magnesium isoglycyrrhizinate alleviates liver injury in obese rats with acute necrotizing pancreatitis

OBJECTIVE

For patients with acute necrotizing pancreatitis (ANP), a high body mass index (BMI) increases the likelihood of acute hepatic injury (AHI). In the current study, we explored whether magnesium isoglycyrrhizinate (MgIg) could alleviate ANP-induced liver injury in obese rats.

METHODS

Sprague-Dawley (SD) rats were selected for the present study, and the ANP model was established by retrograde injection of 5% sodium taurocholate into the biliary-pancreatic duct. Thirty-six SD rats were randomly assigned to six groups: the normal (N), standard rat chow (SRC) normal (SN), SRC ANP (S-ANP), high-fat diet (HFD) normal (H-N), HFD ANP (H-ANP), and MgIg pretreatment HFD ANP (H-ANPT) groups. The rats in the H-ANPT group were treated with MgIg (30 mg/kg) intragastrically for 7 days before the ANP model was established. The rats were sacrificed 12 h after ANP was established, and the blood and pancreatic and liver tissues were collected. Differences in the physiology, pathology and cellular and molecular responses of the rats in each group were examined.

RESULT

Analyses of serum amylase lipase, alanine aminotransferase and aspartate aminotransferase indicated that obesity aggravated ANP-induced hepatic injury and that MgIg improved liver function. The superoxide dismutase, malondialdehyde, M1 macrophage, M2 macrophage, neutrophil, NF-κB, IL-1β and caspase-3 levels in liver tissue showed that MgIg attenuated H-ANP-induced hepatic injury by inhibiting oxidative stress and inflammation.

CONCLUSION

Obesity aggravated ANP-induced liver injury via oxidative stress and inflammatory reactions. MgIg alleviated oxidative stress and decreased the inflammatory reaction, protecting the liver against the AHI induced by ANP in obese rats.

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

Background

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

Methods

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

Results

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

Conclusions

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

Effect of overweight and obesity on weight loss and length of stay in patients with walled-off pancreatic necrosis

OBJECTIVE

The aim of this study was to assess the association between admission weight, weight loss, and length of stay (LOS) in patients with walled-off pancreatic necrosis.

METHODS

We classified the admission body mass index (BMI) of 18.5 to <25 kg/m² as normal weight, 25 to <30 kg/m² as overweight, and ≥30 kg/m² as obesity. The Nutritional Risk Screening score-2002 was calculated to identify patients at risk for undernutrition.

RESULTS

We included 38 patients (61% men, 68% with infected necrosis; 40% normal weight; 60% overweight/obesity). Four patients (11%) required treatment at the semi-intensive care unit, 11 (29%) developed pneumonia, and 10 (26%) developed septicemia. One patient died due to respiratory failure and hemorrhage. The remaining patients were discharged after a median of 49 d (36-64 d). During admission, 14 patients (38%) achieved an energy-protein intake of at least 75% and 17 (46%) achieved ≥70% coverage. The percentage weight loss was different (P < 0.01) for patients with normal weight (4%), overweight (9%), and obesity (14%). There was no difference between groups regarding percentage of energy or protein coverage. Patients with overweight/obesity had a longer hospital LOS (P = 0.016). In univariable regression analysis, overweight, obesity, energy, and protein coverage predicted weight loss. LOS did not predict weight loss. In multivariable regression analysis, overweight and obesity were the only remaining significant predictors of weight loss.

CONCLUSIONS

Patients with walled-off pancreatic necrosis are at considerable risk for undernutrition. A BMI >25 kg/m² predicts greater weight loss and longer LOS.

Metabolic syndrome and acute pancreatitis

AIM

The aim of our study was to investigate the influence of metabolic syndrome on the course of acute pancreatitis determined by disease severity, the presence of local and systemic complications and survival rate.

PATIENTS AND METHODS

609 patients admitted to our hospital in the period from January 1, 2008 up to June 31, 2015 with the diagnosis of acute pancreatitis were analyzed. The diagnosis and the severity of acute pancreatitis were made according to the revised Atlanta classification criteria from 2012.

RESULTS

Of 609 patients with acute pancreatitis, 110 fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome had statistically significantly higher incidence of moderately severe (38.2% vs. 28.5%; p=0.05) and severe (22.7% vs. 12.8%; p=0.01) acute pancreatitis in comparison to those without metabolic syndrome, while patients without metabolic syndrome had higher incidence of mild acute pancreatitis in comparison to those patients with metabolic syndrome (58.7% vs. 39.1%; p<0.001). Patients with metabolic syndrome had a higher number of local and systemic complications, and higher APACHE II score in comparison to patients without metabolic syndrome. In multivariable logistic regression analysis, the presence of metabolic syndrome was independently associated with moderately severe and severe acute pancreatitis. Comparing survival rates, patients suffering from metabolic syndrome had a higher death rate compared to patients without metabolic syndrome (16% vs. 4.5%; p<0.001).

CONCLUSION

The presence of metabolic syndrome at admission portends a higher risk of moderately severe and severe acute pancreatitis, as well as higher mortality rate.

Impact of obesity on outcomes of paediatric acute pancreatitis based on a national administrative database

BACKGROUND

Insufficient information is available on the relationship between obesity and outcome of paediatric patients with acute pancreatitis.

OBJECTIVES

This study aimed to investigate the effect of obesity on outcomes of paediatric patients with acute pancreatitis based on a national administrative database.

METHODS

A total of 500 cases in 416 paediatric patients with acute pancreatitis (aged 5-17 years) were referred from 260 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups according to the presence of obesity: with obesity (n = 65) and without obesity (n = 435). Patient data were collected from the administrative database to compare the prevalence of severe acute pancreatitis, in-hospital mortality, length of stay (LOS) and medical costs between the groups.

RESULTS

Both prevalence of severe acute pancreatitis and in-hospital mortality were significantly higher in paediatric patients with obesity than those without (36.9% vs. 16.3% and 3.1% vs. 0.0%; P < 0.001, respectively). Longer LOS and higher medical costs were also observed in paediatric patients with obesity (25.7 vs. 15.2 days, P < 0.001 and 14 169.5 vs. 7457.7 US dollars, P < 0.001, respectively).

CONCLUSION

This study demonstrated that obesity significantly influenced the outcomes of paediatric acute pancreatitis.

Is Abdominal Fat Distribution Measured by Axial CT Imaging an Indicator of Complications and Mortality in Acute Pancreatitis?

BACKGROUND

Obesity is an important risk-stratifying co-morbidity for many pathological conditions. Controversy exists about its influence in outcomes after acute pancreatitis (AP). This study assessed abdominal fat distribution (subcutaneous, retroperitoneal and intra-abdominal) measured using computer tomography (CT) images and related it to outcomes in patients with AP.

METHODS

The case notes of patients admitted with AP were identified from computerised records from 2008 to the 2013. Image analysis software was used to assess the individual abdominal fat distributions from CT images.

RESULTS

A total of 79 patients were included. There was no relationship between fat distribution and either severity of, or mortality from, AP. Fat distribution was not found to be an independent risk factor on multivariate analysis. There was, however, a positive correlation between retroperitoneal and intra-abdominal fat with APACHE II scores, Ranson and Glasgow score and Multiple Organ Dysfunction score (MODS) on various days following admission (r = 0.421, p = 0.0008; r = 0.469, p < 0.0001; r = 0.398, p = 0.007; r = 0.336, p = 0.011, respectively). On multiple logistical regression analysis, the only variables associated with mortality were Balthazar Severity Index, MODS and EWS with a p value of <0.0001, 0.0019 and 0.0481, respectively.

CONCLUSIONS

Obese patients have worse predicted outcomes as measured by the EWS, MODS and Ranson scores. Abdominal fat distribution, however, was not shown to be directly related to AP severity or mortality. The addition of fat parameters may be of use in prognostic CT severity index models, but from this data, it does not appear to be an independent risk factor of adverse outcome.