New Advances in the Treatment of Acute Pancreatitis

Immediate enteral nutrition can accelerate recovery and be safe in mild acute pancreatitis: A meta-analysis of randomized controlled trials

Objectives

The effect of early enteral nutrition (EN) in patients with acute pancreatitis (AP) has been confirmed. In recent years, some researchers provided new strategy that immediate EN was offered after admission. The effect and safety of immediate EN was unclear because of the different results among studies. The study aimed to implement the meta analysis of randomized controlled trials (RCT) to confirm the effect and safety between the immediate EN group and the early refeeding group.

Methods

Four electronic databases including PubMed, EMBASE, the Cochrane Library and China National Knowledge Internet (CNKI) were searched from inception to July 2021. Endnote X7.0 software was used to manage all the relevant citations. Then data extraction and evaluation of risk of bias for included studies were performed after initial selection and full-text selection. All statistical analyses were performed by Review Manager 5.3 version software.

Results

5 randomized controlled trials (RCT) involving 372 patients were included in the present study. The meta analysis revealed that immediate EN after admission in patients with AP could significantly decrease the length of hospital stay (LOHS) (Mean difference [MD] = 2.57, 95% confidence interval [CI] = 0.41–4.72) and the intolerance of feeding (risk ratio [RR] = 0.78, 95%CI = 0.63–0.95), compared with early refeeding. But immediate EN couldn't significantly decrease the incidence of readmission after discharging (RR = 0.51, 95%CI = 0.12–2.27), the incidence of progression to severe pancreatitis (RR = 0.76, 95%CI = 0.15–3.76), the incidence of complications (RR = 1.12, 95%CI = 0.50–2.49) and the values of C-reactive protein (CRP) and leukocyte counts (MD = 1.05, 95%CI = 0.15–2.26 and MD = 0.11, 95%CI = 0.59–0.80), compared with early refeeding.

Conclusions

Compared with early refeeding, immediate EN after admission could safely reduce LOHS and intolerance of feeding in patients with AP.

Advances in research of early use of prophylactic antibiotics in severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common critical digestive system disease with high mortality, which can lead to multiple organ failure. SAP is often accompanied by massive necrosis of the pancreas, which is prone to secondary infection. Infected pancreatic necrosis is associated with an increased mortality of SAP. Whether early prophylactic use of antibiotics in the treatment of SAP can reduce the incidence of secondary infection is still controversial. This paper reviews the research progress of prophylactic use of antibiotics in the treatment of secondary infection of SAP in recent years.

Long Non-coding RNA FENDRR Modulates Autophagy Through Epigenetic Suppression of ATG7 via Binding PRC2 in Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory, complicated pancreatic disease, carrying significant morbidity and mortality. However, the molecular and cellular mechanisms involved in AP pathogenesis remain to be elucidated. Here, we explore the role of FOXF1 adjacent non-coding developmental regulatory RNA (FENDRR) in AP progression. Caerulein with or without LPS- induced or taurolithocholic acid 3-sulfate (TLC-S)-induced AP mouse models and cell models were performed for the validation of FENDRR expression in vivo and in vitro, respectively. Histopathological examinations of pancreatic tissues were performed to evaluate the severity of AP. Transmission electron microscopy was utilized to visualize the autophagic vacuoles. siRNA specifically targeting FENDRR was further applied. Flow cytometry was employed to assess cell apoptosis. ELISA, immunoflureoscence, and western blotting analysis were also performed to determine the levels of inflammatory cytokines and autophagy activity. RNA immunoprecipitation (RIP) and chromatin immunoprecipitation (ChIP) assays were carried out to reveal the epigenetic regulation of FENDRR on ATG7. Additionally, silencing FENDRR was also verified in AP mouse models. Higher FENDRR and impaired autophagy were displayed in both AP mouse models and cell models. FENDRR knockdown dramatically attenuated caerulein- or TLC-S-induced AR42J cells apoptosis and autophagy suppression. Further mechanistic experiments implied that the action of FENDRR is moderately attributable to its repression of ATG7 via direct interaction with the epigenetic repressor PRC2. Moreover, the silencing of FENDRR significantly induced the promotion of ATG7, thus alleviating the development of AP in vivo. Our study highlights FENDRR as a novel target that may contribute to AP progression, suggesting a therapeutic target for AP treatment.

The challenge of prognostic markers in acute pancreatitis: internist's point of view

Acute pancreatitis, the most frequent hospitalization reason in internal medicine ward among gastrointestinal diseases, is burdened by high mortality rate. The disease manifests mainly in a mild form, but about 20-30% patients have a severe progress that requires intensive care. Patients presenting with acute pancreatitis should be clinically evaluated for organ failure signs and symptoms. Stratifying patients in the first days from symptoms onset is essential to determine therapy and care setting. The aim of our study is to evaluate prognostic factors for acute pancreatitis patients, hospitalized in internal medicine wards, and moreover, understanding the role of various prognostic scores validated in intensive care setting in predicting in-hospital mortality and/or admission to intensive care unit. We conducted a retrospective study enrolling all patients with diagnosis of acute pancreatitis admitted took an internal medicine ward between January 2013 and May 2019. Adverse outcome was considered in-hospital mortality and/or admission to intensive care unit. In total, 146 patients (137 with positive outcome and 9 with adverse outcome) were enrolled. The median age was (67.89 ± 16.44), with a slight prevalence of male (55.1%) compared to female (44.9%). C protein reactive (p = 0.02), creatinine (p = 0.01), sodium (p = 0.05), and troponin I (p = 0.013) after 48 h were significantly increased in patients with adverse outcome. In our study, progression in SOFA score independently increases the probability of adverse outcome in patients hospitalized with acute pancreatitis. SOFA score > 5 is highly predictive of in-hospital mortality (O.R. 32.00; C.I. 6.73-152.5; p = 0.001) compared to other scores. The use of an easy tool, validated in intensive care setting such as SOFA score, might help to better stratify the risk of in-hospital mortality and/or clinical worsening in patients hospitalized with acute pancreatitis in internal medicine ward.

Evaluation of Chinese updated guideline for acute pancreatitis on management of moderately severe and severe acute pancreatitis

BACKGROUND

/Objectives: The management of acute pancreatitis (AP) in China has undergone major changes since the launch of the updated guideline in 2013. This study aimed to evaluate the impact of this guideline on clinical practice and patient outcome.

METHODS

Moderately severe and severe adult AP patients, who were admitted to Peking Union Medical College Hospital from January 1, 2001 to December 31, 2016, were retrospectively included in the study. All enrolled patients were divided into two groups based on the publication date of the updated guideline, as the pre-guideline (Pre) group and post-guideline (Post) group. In-hospital case-fatality rates were compared between two groups after adjusting baseline features, including gender, age, etiology and disease severity. In addition, the associations between specific therapeutic approaches recommended in the updated guideline and in-hospital case-fatality rates were explored.

RESULTS

A total of 475 patients were enrolled in this study, including 273 (57%) in the Pre group and 202 (43%) in the Post group. The adjusted in-hospital case-fatality rate significantly decreased in the Post group (14.3% vs. 5.9%, OR 0.39, 95%CI 0.19-0.82). In the post-hoc analysis, the use of enteral nutrition was a protective factor against in-hospital death (OR: 0.08, 95%CI: 0.03-0.18), while open surgery showed an opposite effect (OR: 3.81, 95%CI: 1.06-13.74). Prophylactic antibiotics was not significantly associated with in-hospital death (OR: 1.00, 95%CI: 0.39-2.60).

CONCLUSIONS

There was a prominent transition in the management of moderately severe and severe AP after the release of the guideline in China in 2013, which made the prognosis better.

Use of antibiotics in acute pancreatitis: ten major concerns

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.

Nutrition Management in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.