An assessment of the severity of interstitial pancreatitis

Association of mean arterial pressure and in-hospital mortality in critically ill patients with acute pancreatitis-associated acute kidney injury: a retrospective cohort study

Acute pancreatitis (AP) is a common gastrointestinal disorder, and acute kidney injury (AKI) is a frequent and severe complication, significantly increasing mortality risk. Mean arterial pressure (MAP) is crucial for maintaining organ perfusion in critically ill patients. However, the optimal MAP target for minimizing mortality in AP patients complicated by AKI (AP-AKI) remains unclear. This retrospective cohort study analyzed data from the MIMIC-IV database, including 934 critically ill adult patients diagnosed with AP-AKI between 2008 and 2019. We investigated the relationship between MAP and in-hospital mortality using logistic regression models, adjusting for demographics, comorbidities, disease severity scores and intensive care interventions. Smooth curve fitting was used to explore potential non-linear associations. Subgroup analyses were performed to assess the impact of MAP across different clinical and demographic groups. Our analysis revealed a non-linear, L-shaped relationship between MAP and in-hospital mortality, with an inflection point at 71.32 mmHg. Below this threshold, increasing MAP was associated with significantly decreased odds of mortality (OR: 0.93, 95% CI: 0.87-0.99, p = 0.026). However, above this threshold, the association was no longer significant (OR: 1.015, 95% CI: 0.98-1.03, p = 0.699). Subgroup analyses showed consistent trends across most subgroups, with the benefit of maintaining MAP above the threshold being most pronounced in AKI stage 1 and 2 patients. This study suggests a potential association between maintaining specific MAP levels, particularly above 71.32 mmHg, and reduced in-hospital mortality in critically ill AP-AKI patients.

MRI and CT radiomics for the diagnosis of acute pancreatitis

Purpose

To evaluate the single and combined diagnostic performances of CT and MRI radiomics for diagnosis of acute pancreatitis (AP).

Materials and methods

We prospectively enrolled 78 patients (mean age 55.7 ± 17 years, 48.7 % male) diagnosed with AP between 2020 and 2022. Patients underwent contrast-enhanced CT (CECT) within 48-72 h of symptoms and MRI ≤ 24 h after CECT. The entire pancreas was manually segmented tridimensionally by two operators on portal venous phase (PVP) CECT images, T2-weighted imaging (WI) MR sequence and non-enhanced and PVP T1-WI MR sequences. A matched control group (n = 77) with normal pancreas was used. Dataset was randomly split into training and test, and various machine learning algorithms were compared. Receiver operating curve analysis was performed.

Results

The T2WI model exhibited significantly better diagnostic performance than CECT and non-enhanced and venous T1WI, with sensitivity, specificity and AUC of 73.3 % (95 % CI: 71.5-74.7), 80.1 % (78.2-83.2), and 0.834 (0.819-0.844) for T2WI (p = 0.001), 74.4 % (71.5-76.4), 58.7 % (56.3-61.1), and 0.654 (0.630-0.677) for non-enhanced T1WI, 62.1 % (60.1-64.2), 78.7 % (77.1-81), and 0.787 (0.771-0.810) for venous T1WI, and 66.4 % (64.8-50.9), 48.4 % (46-50.9), and 0.610 (0.586-0.626) for CECT, respectively.The combination of T2WI with CECT enhanced diagnostic performance compared to T2WI, achieving sensitivity, specificity and AUC of 81.4 % (80-80.3), 78.1 % (75.9-80.2), and 0.911 (0.902-0.920) (p = 0.001).

Conclusion

The MRI radiomics outperformed the CT radiomics model to detect diagnosis of AP and the combination of MRI with CECT showed better performance than single models. The translation of radiomics into clinical practice may improve detection of AP, particularly MRI radiomics.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

Arachidonate 15-lipoxygenase: A promising therapeutic target for alleviating inflammation in acute pancreatitis

This article discusses the significant findings from the study on the transfection of arachidonate 15-lipoxygenase (ALOX15) and its therapeutic potential in managing acute pancreatitis (AP). The research highlights the role of ALOX15 in attenuating inflammatory responses, apoptosis, and autophagy in a cerulein-induced AP murine model. By using a recombinant lentiviral vector for efficient gene delivery, the study provides compelling evidence for the protective effects of ALOX15 transfection on pancreatic tissue. The authors demonstrate that ALOX15 reduces the expression of key inflammatory markers like interleukin-β and tumor necrosis factor α while promoting apoptosis through caspase-3 activation. Furthermore, the modulation of autophagy and structural preservation of pancreatic acinar cells suggest that ALOX15 could be a promising therapeutic target for AP. The implications of these findings are discussed, emphasizing the potential for future clinical translation and further research to explore the molecular mechanisms and therapeutic applications of ALOX15 in inflammatory diseases.

A systematic review of the relationship between gut microbiota and prevalence of pancreatic diseases

Acute pancreatitis (AP) represents one of the most common gastrointestinal (GI) diseases; it can manifest in varying degrees of severity, sometimes leading to a life-threatening condition for the patient. Pancreatic ductal adenocarcinoma (PDAC), due to its high malignancy and uncertain prognosis, is widely regarded as one of the most fatal diseases. The increasing prevalence of AP and PDAC represents a major burden on public health and the healthcare system worldwide. The aim of this systematic review was to discuss the current state of knowledge regarding the relationship between the gut microbiota and the incidence, prognosis, diagnosis and treatment of AP and PDAC. To identify studies that analyzed the relationship between the gut microbiota and the occurrence/development of pancreatic diseases or PDAC, the online databases PubMed, Scopus and Google Scholar were searched between November 2023 and January 2024. Finally, 14 publications met the inclusion criteria (1. were conducted exclusively in humans and/or animals; 2. original, published in English in peer-reviewed journals after 2019; 3. described the relationship between gut microbiota and the occurrence of AP or PDAC). The collected studies indicated significant changes in the gut microbiota of patients with AP and PDAC. Moreover, they highlighted the presence of a relationship between the gut microbiota and the occurrence, course, treatment efficiency and prognosis of the disease in question. Further research is needed to understand precisely the relationship between the gut microbiota and the occurrence of pancreatic diseases and whether it may be a starting point for the development of modern forms of therapy based on the use of prebiotics and/or diet to restore the normal composition of the intestinal bacteria.

The mechanism of transcutaneous gastric pacing treatment on gastrointestinal motility recovery and inflammation improvement in early-stage acute pancreatitis patients

PURPOSE

Acute pancreatitis (AP) is often accompanied by gastrointestinal motility disorders. The purpose of this study was to investigate the efficacy and possible mechanism of transcutaneous gastric pacing (TGP) in early-stage AP patients.

MATERIALS AND METHODS

Sixty-five AP patients were randomly divided into conventional treatment group and TGP group. The serum ghrelin and vasoactive intestinal peptide (VIP) were used to assess the possible gastrointestinal hormonal mechanism involved. The parameters of electrogastrogram (EGG) were used to evaluate the gastric motility in AP patients. The first defecation time was used to assess the recovery of intestinal motility. The heart rate variability (HRV) test was performed to assess autonomic nervous function.

RESULTS

Compared with the conventional treatment group, the TGP treatment significantly improved symptoms in early AP patients, and shortened the first defecation time (p < 0.05) and the hospital days (p < 0.05). The level of VIP (P < 0.05) was also decreased in TGP group. The percentage of normal gastric slow waves (GSWS) (p < 0.05) was increased. The interleukin (IL)-6 level was decreased (P < 0.05). Concurrently, the vagal activity (HF) was increased (p < 0.01), the sympathetic activity (LF) was decreased (p < 0.01), and the ratio of sympathetic vagal (LF/HF) was decreased (p < 0.01).

CONCLUSIONS

The TGP treatment significantly improves the clinical symptoms in early AP patients. It also increases the percentage of normal GSWS. The therapeutic effect of TGP may be caused by autonomic nervous function mechanisms.

Association between hematocrit-to-albumin ratio and acute kidney injury in patients with acute pancreatitis: a retrospective cohort study

Acute pancreatitis (AP) can result in acute kidney injury (AKI), which is linked to poor outcomes. We aimed to assess the relationship between the hematocrit-to-albumin ratio (HAR) and AKI in this population. This retrospective cohort study included consecutive patients diagnosed with AP and admitted to hospital. Data were systematically extracted from electronic medical records, covering baseline demographic and clinical characteristics. Total 1514 AP patients were enrolled, with 17% (257/1514) developing AKI. Multivariable-adjusted regression analysis, curve fitting, threshold effects analyses, and subgroup analyses were conducted to evaluate the relationship between HAR and AKI incidence in AP patients. Compared to the reference tertile of HAR, the adjusted OR values for the lower and higher tertiles of HAR were 1.25 (95% CI, 0.82-1.91, P = 0.297) and 1.50 (95% CI, 1.03-2.20, P = 0.037), respectively, after adjusting for covariates. The curve fitting results showed a J-shaped relationship between HAR and AKI (non-linear, p = 0.001), with an inflection point of 8.969. Furthermore, validation using the Medical Information Mart for Intensive Care (MIMIC-IV) database AP population revealed a similar relationship with an inflection point at 10.257. Our findings suggest a J-shaped relationship between HAR and AKI in AP patients, indicating higher risk of AKI when HAR exceeds 8.969.

Circulating Protectin D1 and Neutrophils Extracellular Traps in the Diagnosis and Progression of Acute Pancreatitis

Purpose

Protectin D1 (PD1), a biologically active molecule derived from docosahexaenoic acid (DHA), plays a major role in the body's endogenous lipid-mediated inflammatory response. The study aims to explore the relationship between PD1, inflammatory response and the severity of acute pancreatitis (AP).

Patients and Methods

Sixty consecutive AP patients within 72h of disease onset were enrolled as the study group, a further thirty healthy people were enrolled as the control group. General demographics collected at the time of enrollment. Serum PD1, Citrullinated Histone 3 (CitH3), myeloperoxidase-Deoxyribonucleic acid (MPO-DNA), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) level were measured in AP patients on enrollment day 0, day 1, day 3 and day 7. Meanwhile, the Acute Physiology and Chronic Health evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores were also evaluated on day 0, day 1, day 3 and day 7.

Results

AP was severe in 29 patients (48.3%), moderately severe acute pancreatitis (MSAP) was found in 9 patients (15%), and mild acute pancreatitis (MAP) was found in 22 patients (36.7%). The level of PD1, CitH3 and MPO-DNA were statistically significantly higher in AP patients than in the healthy population. Serum PD1, CitH3 and MPO-DNA concentration increased with AP severity. In AP patients, PD1 has a strong linear association with TNF-α, CitH3 and MPO-DNA. The AUC for SAP predicted by PD1 was 0.938. The calculated cut-off point for prognosis SAP is 7.94 pg/mL. The AUC for infected pancreatic necrosis (IPN) predicted by PD1 was 0.836 and the cut-off point was 8.65 pg/mL. The AUC for organ failure (OF) predicted by PD1 was 0.719 and the cut-off point was 7.94 pg/mL.

Conclusion

PD1 is associated with both the presence of AP and the severity of pancreatitis.

Groove pancreatitis: From enigma to future directions-A comprehensive review

Groove pancreatitis (GP) is a rare and clinically distinct form of chronic pancreatitis affecting the pancreaticoduodenal groove comprising the head of the pancreas, duodenum, and the common bile duct. It is more prevalent in individuals in their 4-5th decade of life and disproportionately affects men compared with women. Excessive alcohol consumption, tobacco smoking, pancreatic ductal stones, pancreatic divisum, annular pancreas, ectopic pancreas, duodenal wall thickening, and peptic ulcers are significant risk factors implicated in the development of GP. The usual presenting symptoms include severe abdominal pain, nausea, vomiting, diarrhea, weight loss, and jaundice. Establishing a diagnosis of GP is often challenging due to significant clinical and radiological overlap with numerous benign and malignant conditions affecting the same anatomical location. This can lead to a delay in initiation of treatment leading to increasing morbidity, mortality, and complication rates. Promising research in artificial intelligence (AI) has garnered immense interest in recent years. Due to its widespread application in diagnostic imaging with a high degree of sensitivity and specificity, AI has the potential of becoming a vital tool in differentiating GP from pancreatic malignancies, thereby preventing a missed or delayed diagnosis. In this article, we provide a comprehensive review of GP, covering the etiology, pathogenesis, clinical presentation, radiological and endoscopic evaluation, management strategies, and future directions. This article also aims to increase awareness about this lesser known and often-misdiagnosed clinical entity amongst clinicians to ultimately improve patient outcomes.

Percutaneous Biopsy and Drainage of the Pancreas

Percutaneous biopsy and drainage of pancreatic lesions, though less frequent due to advancements in endoscopic techniques, remain vital skills for interventional radiologists. This review details the indications, options, approaches, and technical considerations for pancreatic biopsy and (peri)pancreatic fluid drainage by examining a comprehensive range of literature. The importance of a multidisciplinary approach is emphasized to ensure optimal patient care and outcomes, highlighting current best practices and recent advancements.

Appropriate Use of Antibiotics in Acute Pancreatitis: A Scoping Review

BACKGROUND

While selective use of antibiotics for infected pancreatic necrosis (IPN) in acute pancreatitis (AP) is recommended, studies indicate a high rate of inadequate treatment.

METHODS

A search of PubMed, Scopus, and Cochrane databases was conducted, focusing on primary research and meta-analyses. Data were categorized based on core concepts, and a narrative synthesis was performed.

RESULTS

The search identified a total of 1016 publications. After evaluating 203 full texts and additional sources from the grey literature, 80 studies were included in the review. The answers obtained were: (1) Preventive treatment does not decrease the incidence of IPN or mortality. Given the risks of bacterial resistance and fungal infections, antibiotics should be reserved for highly suspected or confirmed IPN; (2) The diagnosis of IPN does not always require microbiological samples, as clinical suspicion or computed tomography signs can suffice. Early diagnosis and treatment may be improved by using biomarkers such as procalcitonin and novel microbiological methods; (3) When indicated, early initiation of antibiotics is a key determinant in reducing mortality associated with IPN; (4) Antibiotics with good penetration into pancreatic tissue covering Gram-negative and Gram-positive bacteria should be used. Routine antifungal therapy is not recommended; (5) The step-up approach, including antibiotics, is the standard for IPN management; (6) Antibiotic duration should be kept to a minimum and should be based on the quality of source control and patient condition.

CONCLUSIONS

Early antibiotic therapy is essential for the treatment of IPN, but prophylactic antibiotics are not recommended in AP. High-quality randomized controlled trials are required to better understand the role of antibiotics and antifungals in AP management.

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis

BACKGROUND

Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated.

METHODS

This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates.

RESULTS

Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0).

CONCLUSIONS

Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

Endoscopic Drainage of Pancreatic Fluid Collections

Pancreatic fluid collections (PFCs) are commonly encountered complications of acute and chronic pancreatitis. With the advancement of endoscopic ultrasound (EUS) techniques and devices, EUS-directed transmural drainage of symptomatic or infected PFCs has become the standard of care. Traditionally, plastic stents have been used for drainage, although lumen-apposing metal stents (LAMSs) are now favored by most endoscopists due to ease of use and reduced procedure time. While safety has been repeatedly demonstrated, follow-up care for these patients is critical as delayed adverse events of indwelling drains are known to occur.

Reversal of Fatty Liver With Regression of Acute Necrotizing Pancreatitis: A Rare Case

Acute pancreatitis is a severe inflammatory condition that can lead to systemic repercussions, one of which is the development of hepatic steatosis (fatty liver). The accumulation of fat in liver cells can complicate the course of pancreatitis, exacerbating inflammation and causing additional metabolic disturbances. The presence of fatty liver in the context of acute pancreatitis can thus worsen the overall clinical picture, making management more challenging and potentially leading to further complications. Here, we discuss a rare case of a 34-year-old female who demonstrated the reversal of fatty liver following the improvement of acute pancreatitis. This case highlights the dynamic relationship between acute pancreatitis and hepatic steatosis, illustrating that effective management of pancreatitis can lead to significant improvements in associated conditions such as fatty liver.

Identification of Biomarkers Associated with Oxidative Stress and Immune Cells in Acute Pancreatitis

Purpose

Oxidative stress promotes disease progression by stimulating the humoral and cellular immune responses. However, the molecular mechanisms underlying oxidative stress and immune responses in acute pancreatitis (AP) have not been extensively studied.

Patients and Methods

We analyzed the GSE194331 dataset and oxidative stress-related genes (OSRGs). We identified differentially expressed immune cell-associated OSRGs (DE-ICA-OSRGs) by overlapping key module genes from weighted gene co-expression network analysis, OSRGs, and DEGs between AP and normal samples. Functional enrichment analysis was performed to investigate the functions of DE-ICA-OSRGs. We then filtered diagnostic genes using receiver operating characteristic curves and investigated their molecular mechanisms using single-gene set enrichment analysis (GSEA). We also explored the correlation between diagnostic genes and differential immune cells. Finally, we constructed a transcription factor-microRNA-messenger RNA (TF-miRNA-mRNA) network of biomarkers.

Results

In this study, three DE-ICA-OSRGs (ARG1, NME8 and VNN1) were filtered by overlapping key module genes, OSRGs and DEGs. Functional enrichment results revealed that DE-ICA-OSRGs were involved in the cellular response to reactive oxygen species and arginine biosynthesis. Latterly, a total of two diagnostic genes (ARG1 and VNN1) were derived and their expression was higher in the AP group than in the normal group. The single-gene GSEA enrichment results revealed that diagnostic genes were mainly enriched in macroautophagy and Toll-like receptor signaling pathways. Correlation analysis revealed that CD8 T cells, resting memory T CD4 cells, and resting NK cells were negatively correlated with ARG1, and neutrophils were positively correlated with ARG1, which was consistent with that of VNN1. The TF-miRNA-mRNA regulatory network included 11 miRNAs, 2 mRNAs, 10 transcription factors (TFs), and 26 pairs of regulatory relationships, like NFKB1-has-miR-2909-VNN1.

Conclusion

In this study, two immune cell oxidative stress-related AP diagnostic genes (ARG1 and VNN1) were screened to offer a new reference for the diagnosis of patients with AP.

Choledochoscopy combined with double-cannula lavage in the treatment of acute pancreatitis with encapsulated necrosis and the analysis of related inflammatory indexes

OBJECTIVE

This study aimed to evaluate the application of choledochoscopy combined with double-cannula lavage in the treatment of acute pancreatitis (AP) with encapsulated necrosis and analyzed related inflammatory indexes.

METHODS

Thirty patients with AP with encapsulated necrosis were enrolled and treated with choledochoscopy and double-cannula lavage. Serum white blood cell (WBC), procalcitonin (PCT), C-reactive protein (CRP), interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha (TNF-α), and related inflammatory indexes were detected before and after surgery.

RESULTS

All of the participants who underwent the surgery recovered well and were discharged without serious complications; no deaths occurred. The serum WBC, PCT, and CRP of patients after surgery decreased compared with before the procedure, and the differences in WBC and CRP were statistically significant (P < 0.05); the difference in PCT was not statistically significant (P > 0.05). Postoperatively, IL-6, IL-8, and TNF-α levels were higher than before surgery, and the differences were statistically significant (P < 0.05).

CONCLUSION

The surgical method presented herein effectively controlled and alleviated the infection of patients; it also did not increase the risk of infection and can thus be considered a safe and effective surgical method.

Repetitive endoscopic drainage as initial intervention is safe and effective for early treatment of pancreatic necrotic collections

BACKGROUND

While endoscopic step-up approach with delayed drainage (more than 28 days from diagnosis) was shown to produce the best outcomes in the treatment of pancreatic walled-off necrosis (WON), we assessed our single centre experience of early versus delayed endoscopic drainage of pancreatic necrotic collections.

METHODS

Patients who underwent endoscopic drainage of pancreatic necrotic collections between 2011 and 2022 under Monash Health were identified. They were excluded if below 18 years old or their follow up data were missing. The included patients' medical records, pathology results, and imaging findings were retrospectively reviewed.

RESULTS

A total of 60 patients were included. 31.58% required percutaneous drainage and 15% received either endoscopic or surgical necrosectomy. The disease related mortality was 8.47% and the average length of stay (LOS) was 70.92 days. No significant difference was shown in disease-related mortality (10.5% vs. 7.5%, P = 0.697) or LOS (75.35 vs. 68.7, P = 0.644) between early and delayed drainage cohorts, but patients who received early drainage have higher qSOFA score on the day of drainage (2 vs. 0, P = 0.004).

DISCUSSION

Repetitive endoscopic drainage with selective percutaneous drainage is effective in the management of pancreatic necrotic collections. Early drainage should be considered in patients who developed severe sepsis.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Microscopic Colitis and Risk of Incident Acute Pancreatitis: A Nationwide Population-Based Matched Cohort Study

INTRODUCTION

Several gastrointestinal diseases have been linked to acute pancreatitis, but the risk of acute pancreatitis in microscopic colitis (MC) has not been studied.

METHODS

We conducted a nationwide, population-based, matched cohort study in Sweden of 12,140 patients with biopsy-verified MC (diagnosed in 2003-2017), 57,806 matched reference individuals, and 12,781 siblings without MC with a follow-up until 2021. Data on MC were obtained from all of Sweden's regional pathology registers (n = 28) through the ESPRESSO cohort. Data on acute pancreatitis were collected from the National Patient Register. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using Cox regression.

RESULTS

During a mean follow-up of 9.9 years (SD = 4.3), 146 patients with MC and 437 reference individuals were diagnosed with acute pancreatitis (127.8 vs 80.1 per 100,000 person-years), corresponding to an aHR of 1.57 (95% CI = 1.30-1.90). Moreover, we found a positive association between MC and acute nongallstone-related pancreatitis (aHR 1.99 [95% CI = 1.57-2.51]), but not with acute gallstone-related pancreatitis (aHR 1.08 [95% CI = 0.78-1.49]). Comparing patients with MC with their unaffected siblings yielded an aHR of 1.28 (95% CI = 0.92-1.78). The risk of acute pancreatitis remained elevated also for patients with MC with a follow-up exceeding 10 years (aHR 1.75 [95% CI = 1.14-2.67]).

DISCUSSION

This nationwide study of more than 12,000 patients with MC demonstrated an increased risk of acute pancreatitis after MC. Hence, clinicians should have a low threshold for the evaluation of acute pancreatitis in patients with MC. In addition, these patients should receive advice and care aimed at reducing the risk of acute pancreatitis.

Acute Pancreatitis: Current Clinical Approaches, Molecular Pathophysiology, and Potential Therapeutics

OBJECTIVE

Severe acute pancreatitis (SAP), pancreatic inflammation leading to multiorgan failure, is associated with high morbidity and mortality. There is a critical need to identify novel therapeutic strategies to improve clinical outcomes for SAP patients.

MATERIALS AND METHODS

A comprehensive literature review was performed to identify current clinical strategies, known molecular pathophysiology, and potential therapeutic targets for SAP.

RESULTS

Current clinical approaches focus on determining which patients will likely develop SAP. However, therapeutic options are limited to supportive care and fluid resuscitation. The application of a novel 5-cytokine panel accurately predicting disease outcomes in SAP suggests that molecular approaches will improve impact of future clinical trials in AP.

CONCLUSIONS

Inflammatory outcomes in acute pancreatitis are driven by several unique molecular signals, which compound to promote both local and systemic inflammation. The identification of master cytokine regulators is critical to developing therapeutics, which reduce inflammation through several mechanisms.

The role of high serum triglyceride levels on pancreatic necrosis development and related complications

BACKGROUND

The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis.

METHODS

We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150-199 mg/dL), High TG (200-499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis.

RESULTS

A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI - 6.27, p < 0.001).

CONCLUSIONS

An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.

Impact of sex and comorbid diabetes on hospitalization outcomes in acute pancreatitis: A large United States population-based study

BACKGROUNDS

Data on the association between comorbid diabetes mellitus (DM) and acute pancreatitis (AP) remains limited. Utilizing a large, nationwide database, we aimed to examine the impact of comorbid diabetes mellitus on patients admitted for acute pancreatitis.

METHODS

This was a retrospective case-control study of adult patients with AP utilizing the National Inpatient Sample from 2015-2018, using ICD-10 codes. Hospitalization outcomes of patients admitted for AP with comorbid DM were compared to those without comorbid DM at the time of admission. The primary outcome was a mortality difference between the cohorts. Multivariable-adjusted cox proportional hazards model analysis was performed. Data was analyzed as both sex aggregated, and sex segregated.

RESULTS

940,789 adult patients with AP were included, of which 256,330 (27.3%) had comorbid DM. Comorbid DM was associated with a 31% increased risk of inpatient mortality (aOR: 1.31; p = 0.004), a 53% increased risk of developing sepsis (aOR: 1.53; p = 0.002), increased hospital length of stay (LOS) (4.5 days vs. 3.7 days; p < 0.001), and hospital costs ($9934 vs. $8486; p < 0.001). Whites admitted for AP with comorbid DM were at a 49% increased risk of mortality as compared to Hispanics (aOR: 1.49; p < 0.0001). Different comorbidities had sex-specific risks; men admitted for AP with comorbid DM were at a 28% increased risk of mortality (aOR: 1.28; p < 0.0001) as compared to women. Men with comorbid DM plus obesity or hypertension were also at increased risk of mortality as compared to women, whereas women with comorbid DM plus renal failure were at greater risk of mortality as compared to men.

CONCLUSIONS

Comorbid DM appears to be a risk factor for adverse hospitalization outcomes in patients admitted for AP with male sex and race as additional risk factors. Future prospective studies are warranted to confirm these findings to better risk stratify this patient population.

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Factors Predicting the Development of Necrosis in Patients Presenting With Edematous Acute Pancreatitis

OBJECTIVES

There is no marker that can accurately predict the development of pancreatic necrosis in edematous acute pancreatitis (AP). This study aimed to investigate the factors associated with necrosis development in cases of edematous AP and to create an easy-to-use scoring system.

METHODS

We retrospectively reviewed patients diagnosed with edematous AP between 2010 and 2021. Among the patients, those who were found to have developed necrosis during follow-up were categorized as the necrotizing group, whereas the others constituted the edematous group.

RESULTS

With multivariate analysis, white blood cell, hematocrit, lactate dehydrogenase, and C-reactive protein levels at the 48th hour were revealed to be independent risk factors for necrosis. Using these 4 independent predictors, the Necrosis Development Score 48 (NDS-48) was derived. While the cutoff value was 2.5, the sensitivity and specificity of the NDS-48 for necrosis were 92.5% and 85.9%, respectively. The area under the curve value of the NDS-48 for necrosis was 0.949 (95% confidence interval, 0.920-0.977).

CONCLUSIONS

White blood cell, hematocrit, lactate dehydrogenase, and C-reactive protein levels at the 48th hour are independent predictors of necrosis development. The NDS-48, a new scoring system created with these 4 predictors, satisfactorily predicted the development of necrosis.

Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram

BACKGROUND

Early prediction of persistent organ failure (POF) is important for triage and timely treatment of patients with acute pancreatitis (AP).

METHODS

All AP patients were consecutively admitted within 48 h of symptom onset. A nomogram was developed to predict POF on admission using data from a retrospective training cohort, validated by two prospective cohorts. The clinical utility of the nomogram was defined by concordance index (C-index), decision curve analysis (DCA), and clinical impact curve (CIC), while the performance by post-test probability.

RESULTS

There were 816, 398, and 880 patients in the training, internal and external validation cohorts, respectively. Six independent predictors determined by logistic regression analysis were age, respiratory rate, albumin, lactate dehydrogenase, oxygen support, and pleural effusion and were included in the nomogram (web-based calculator: https://shina.shinyapps.io/DynNomapp/). This nomogram had reasonable predictive ability (C-indexes 0.88/0.91/0.81 for each cohort) and promising clinical utility (DCA and CIC). The nomogram had a positive likelihood ratio and post-test probability of developing POF in the training, internal and external validation cohorts of 4.26/31.7%, 7.89/39.1%, and 2.75/41%, respectively, superior or equal to other prognostic scores.

CONCLUSIONS

This nomogram can predict POF of AP patients and should be considered for clinical practice and trial allocation.

Akut Pankreas İltihabı Süresince Metillenmiş Arginin Rezidüleri ve İlişkili Amino Asitlerdeki Değişimler

Aim: The extent of the spread of inflammation determines the severity of acute pancreatitis (AP). Methylated arginine residues (MAR), a type of inflammatory mediator, reduce nitric oxide levels and cause vasoconstriction-induced endothelial damage. This study aimed to investigate MAR and related amino acids during acute pancreatic inflammation. Material and Method: This prospective, quasi-experimental study was conducted with patients diagnosed with AP and an age-matched control group. The patient samples were taken during the diagnosis and recovery time, whereas during the study for the control group. Mainly, Asymmetric dimethylarginine (ADMA), Arginine (ARG), Citrulline (CIT), and related chemicals were studied via a mass spectrometer. Results: A total of 30 patients with AP (mean age=53.3±17.8) and 30 controls (mean age=53.4±18.0) were included in the study. All patients were identified as non-severe (n=8) and severe (n=22). A decrease was detected in the patients' ADMA levels compared to the control group (p=0.01). MAR did not differ concerning disease severity (p > 0.05). However, MAR levels decreased higher in patients with diabetes or chronic kidney disease (CKD). Between the two samplings, the ARG level and ARG to ADMA ratio increased, while the MAR and CIT to ARG ratio decreased. Conclusion: Our results showed that MAR levels decreased with AP recovery. The start of a decrease in the high-level blood MAR may indicate the healing of pancreatic inflammation. AP inflammation may be more destructive in patients with diabetes or CKD.

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholangiopancreatography in defining etiology of idiopathic acute pancreatitis. World J Gastrointest Endosc 2022;14:376-386. [DOI: 10.4253/wjge.v14.i6.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

About 10%-30% of acute pancreatitis remain idiopathic (IAP) even after clinical and imaging tests, including abdominal ultrasound (US), contrast-enhanced computed tomography (CECT) and magnetic resonance cholangiopancreatography (MRCP). This is a relevant issue, as up to 20% of patients with IAP have recurrent episodes and 26% of them develop chronic pancreatitis. Few data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional techniques.

AIM

To evaluate the diagnostic gain after failure of one or more previous cross-sectional exams.

METHODS

We retrospectively collected data about consecutive patients with AP and at least one negative test between US, CECT and MRCP, who underwent linear EUS between January 2017 and December 2020. We investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these cross-sectional imaging techniques for the etiologic diagnosis of AP. Types and frequency of EUS diagnosis were also analyzed, and EUS diagnosis was compared with the clinical parameters. After EUS, patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis recurrence.

RESULTS

We enrolled 81 patients (63% males, mean age 61 ± 18, 23% with previous cholecystectomy, 17% with recurrent pancreatitis). Overall EUS diagnostic yield for AP etiological diagnosis was 79% (20% lithiasis, 31% acute on chronic pancreatitis, 14% pancreatic solid or cystic lesions, 5% pancreas divisum, 5% autoimmune pancreatitis, 5% ductal abnormalities), while 21% remained idiopathic. US, CECT and MRCP, taken alone or in combination, led to AP etiological diagnosis in 16 (20%) patients; among the remaining 65 patients, 49 (75%) obtained a diagnosis at EUS, with an overall EUS diagnostic gain of 61%. Sixty-eight patients had negative US; among them, EUS allowed etiological diagnosis in 59 (87%). Sixty-three patients had a negative CECT; among them, 47 (74%) obtained diagnosis with EUS. Twenty-four had a negative MRCP; among them, 20 (83%) had EUS diagnosis. Twenty-one had negative CT + MRCP, of which 17 (81%) had EUS diagnosis, with a EUS diagnostic gain of 63%. Patients with biliary etiology and without previous cholecystectomy had higher median values of alanine aminotransferase (154 vs 25, P = 0.010), aspartate aminotransferase (95 vs 29, P = 0.018), direct bilirubin (1.2 vs 0.6, P = 0.015), gamma-glutamyl transpeptidase (180 vs 48, P = 0.006) and alkaline phosphatase (150 vs 72, P = 0.015) Chronic pancreatitis diagnosis was more frequent in patients with recurrent pancreatitis at baseline (82% vs 21%, P < 0.001). During the follow-up, AP recurred in 3 patients, one of which remained idiopathic.

CONCLUSION

EUS is a good test to define AP etiology. It showed a 63% diagnostic gain over CECT + MRCP. In suitable patients, EUS should always be performed in cases of IAP. Further prospective studies are needed.

Role of antioxidants and oxidative stress in the evolution of acute pancreatitis (Review)

Acute pancreatitis (AP) is a severe disease with a high prevalence and 3 to 15% mortality worldwide, which can represent an important challenge for the physician. Oxidative stress and antioxidants are involved in AP progression. The mechanisms responsible for the onset and progression of AP are still poorly understood. Previous studies have highlighted the important contribution of antioxidants and oxidative stress in AP. The existence of a relationship between oxidative stress and antioxidants in AP is unquestionable, although a more accurate understanding of the mechanistic pathways involved is required to create a solid basis for potential prevention or treatment strategies. Further investigation is needed to clarify the role of antioxidant status and the severity of AP and to determine the association between oxidative stress and pancreatic enzyme activities. Antioxidant therapy may represent an interesting option for the management of patients with AP, although additional information about the effectiveness of this potential treatment is required.

A Systematic Review and Meta-analysis of Opioids vs Nonopioids in Acute Pancreatitis

Background and Aims

Although abdominal pain is one of the major criteria to diagnose acute pancreatitis (AP), there are no standardized guidelines to treat this troublesome symptom in the hospital setting. The aims of the study are to conduct a meta-analysis and to assess the efficacy of nonopioids vs opioids for pain management in AP.

Methods

We searched the medical literature through May 2021 to identify randomized controlled trials that examined the efficacy of opioids with nonopioids in AP pain management. Efficacy was reported as odds ratio (OR) with 95% confidence intervals (CIs) of each comparison tested.

Results

We identified 7 eligible randomized controlled trials, containing 389 patients. No significant difference in terms of pain intensity at day 1 (OR 0.82, 95% CI -2.55 to 4.19) was found between opioids and nonopioids. Nonopioids have a significantly high risk of supplementary analgesic use compared with opioids (OR 3.87, 95% CI 1.25-12.04). However, this significance is not seen when comparing nonsteroidal anti-inflammatory drugs and paracetamol with opioids (OR 1.67, 95% CI 0.73-3.82) after excluding trials with procaine. Opioids did not show a significant increase in the complications of pancreatitis, nausea and vomiting, sedation, and deaths when compared with nonopioids.

Conclusion

We found nonopioids, especially nonsteroidal anti-inflammatory drugs and paracetamol, can provide adequate pain relief in patients with AP with no change in supplementary analgesic use and adverse events when compared with opioids. Further research is needed to optimize the use of nonopioids along or in combination with opioids for better pain control in patients with AP.

The relationship between neutrophil-lymphocyte ratio and clinal laboratory data in acute pancreatitis

Introduction: Neutrophil-lymphocyte ratio (NLR) is one of the laboratory biomarkers used in clinical practice to predict severity and mortality of acute pancreatitis (AP), however, there is currently insufficient information about the changes of NLR in the dynamics in relationship with other clinical and laboratory data. Aims: To assess the relationship between NLR values and other demographics, clinical and simple laboratory data in patients with acute pancreatitis. Methods: The data of two hundred twenty-nine patients with AP were analyzed. All patients were divided into two groups: the group with a positive outcome and the group with a fatal outcome. NLR was counted on the 1st, 3rd and 5th day after admission in each group. The dynamics of NLR index by groups and days, as well as its correlation with other 18 simple laboratory parameters were evaluated. Results: The level of NLR rate itself was significantly higher on the 1st, 3rd and 5th day in the group with the fatal result compared with the group with the positive result (p < 0.05). In patients with AP with the positive result of treatment, there was a gradual decrease in the rate between the 1st and the 3rd day (-21.8%) (p < 0.05). The overall dynamics of the indicator between the 1st and the 5th day was -21.5%. In contrast to the group of patients with the fatal outcome, despite the infusion therapy, there was an increase in NLR rate between the 1st and 3rd day of +15.7%. The overall dynamics between the 1st and 5th day was -34.0%. A significant negative relationship of the Spearman's rank correlation coefficient between NLR on the 1st and 3rd day with the fatal outcome was revealed. The highest reliability of this indicator was found on the 3rd day after admission (p < 0.0001). In the group of patients with a positive result, a correlation between NLR on the 1st day and stabs on the 1st day, segmental forms on the 1st day, serum amylase on the 1st day was found. A very high correlation was found with the level of lymphocytes on the 1st day (rs = -0.98, p < 0001). In the group of patients with the fatal outcome, a statistically significant correlation (p < 0.05) of moderate strength was found between the value of NLR and the following indicators: glucose level on the 1st day, total protein on the 5th day, prothrombin index on the 5th day. A high correlation was found with the level of segmental forms on the 1st day (rs = 0.7) and a very high correlation with the level of lymphocytes on the 1st day (rs = -0.99). Conclusions: There was a significant increase in NLR on the 1st, 3rd, and 5th day in the group of patients with AP with the fatal outcome compared with the group of patients with AP with the positive result. Elevated NLR levels on the 1st and 3rd day seem to be associated with hospital mortality in patients with AP. No correlation was found between NLR rate and clinical data in the group with fatal outcome. The main indicators among simple laboratory parameters for determining the predictors of lethal outcome in AP in different periods after hospitalization were: the level of blood glucose, lymphocytes, total protein, serum amylase, prothrombin index.

Progress in research of minimally invasive therapy of local complications of acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas that can be life-threatening. Patients with severe acute pancreatitis require further rescue treatment in the intensive care unit. In recent years, treatment of local complications of acute pancreatitis has undergone considerable changes, including multidisciplinary team mode and individualized treatment scheme, and traditional open surgery has been gradually replaced by minimally invasive treatment. This article summarizes the progress in research on minimally invasive therapy of the local complications of acute pancreatitis in recent years.

Current epidemiological trends and in-hospital mortality of acute pancreatitis in Germany: a systematic analysis of standardized hospital discharge data between 2008 and 2017

BACKGROUND

Acute pancreatitis (AP) represents a common gastrointestinal disorder. Complicated disease courses in particular still represent a major clinical challenge and are associated with high mortality. Evaluation of existing data sets and their careful interpretation can support a rational discussion to optimize outcomes of this common gastrointestinal disease.

METHODS

We used standardized hospital discharge data provided by the Federal Statistical Office of Germany to evaluate hospital mortality and current developments of AP in Germany between 2008 and 2017.

RESULTS

In this analysis, 516,618 hospitalized AP cases were included. Main disease etiologies featured biliary (29.9%) and alcoholic (22.7%) AP. The annual frequency of AP increased from 48,858 (2008) to 52,611 (2017), mainly due to a rising incidence of biliary AP. Average hospital mortality was 2.85% and significantly improved over time. While uncomplicated AP had low hospital mortality (1.38%), the presence of organ complications was associated with a mortality of 12.34%. The necessity of mechanical ventilation dramatically increased hospital mortality to 44.06%. Hospital mortality was significantly higher in female patients (3.31%) than males (2.55%) and showed a stepwise increase with patient age. We further identified type 2 diabetes mellitus and obesity as factors associated with increased hospital mortality. Hospital mortality was lowest among patients treated at departments specializing in gastroenterology. Finally, high case volume centers (defined as >98 annual AP cases) had the lowest hospital mortality for patients with complicated courses of AP.

CONCLUSION

With over 50,000 annual hospitalization cases, AP is one of the most important inpatient treatment indications in gastroenterology in Germany. Overall, AP mortality has improved in recent years, presumably due to improved interdisciplinary treatment concepts. In this study, we identified important clinical and epidemiological risk factors for an unfavorable course, which could help to improve risk prediction and triaging, and thus the management of AP.

Impacts of body composition parameters and liver cirrhosis on the severity of alcoholic acute pancreatitis

AIM

Liver cirrhosis and features of muscle or adipose tissues may affect the severity of acute pancreatitis (AP). We aimed to evaluate the impact of body composition parameters and liver cirrhosis on the severity of AP in patients with alcohol-induced AP (AAP).

METHODS

Patients with presumed AAP who underwent CT within one week after admission were retrospectively enrolled. L3 sectional areas of abdominal fat and muscle, and mean muscle attenuations (MMAs) were quantified. The presence of liver cirrhosis was determined using clinical and CT findings. Factors potentially associated with moderately severe or severe AP were included in the multivariable logistic regression analysis.

RESULTS

A total of 242 patients (47.0 ± 12.6 years, 215 males) with presumed AAP were included. The mild and moderately severe/severe (MSS) groups included 137 (56.6%) and 105 patients (43.4%), respectively. Patients in the MSS group had higher rates of liver cirrhosis, organ failure, and local complications. Among body composition parameters, mean MMA (33.4 vs 36.8 HU, P<0.0001) and abdominal muscle mass (126.5 vs 135.1 cm2, P = 0.029) were significantly lower in the MSS group. The presence of liver cirrhosis (OR, 4.192; 95% CI, 1.620-10.848) was found to be a significant risk factor for moderately severe or severe AP by multivariable analysis.

CONCLUSION

The results of this study suggest that liver cirrhosis has a significant impact on the severity of AAP. Of the body composition parameters examined, MMA and abdominal muscle mass showed potential as promising predictors.

MR Imaging for Early Extrapancreatic Necrosis in Acute Pancreatitis

RATIONALE AND OBJECTIVES

To study the MRI characteristics of early extrapancreatic necrosis and compare them with those of peripancreatic fluid collections in acute pancreatitis (AP).

MATERIALS AND METHODS

This retrospective study enrolled 70 AP patients who had extrapancreatic collections visible on MRI within 1 week of onset. Extrapancreatic collections were divided into extrapancreatic necrosis and peripancreatic fluid collections based on follow-up MRI, CT, or pathology. The number and area of extrapancreatic collections, extrapancreatic inflammation on MRI (EPIM) score, MR severity index score and clinical characteristics were evaluated and compared between the two groups.

RESULTS

Of the seventy AP patients, 32 (45.7%) had extrapancreatic necrosis, and 38 (54.3%) had peripancreatic fluid collections. The number and area of extrapancreatic collections, MR severity index score, EPIM score, and prevalence of associated hemorrhage were significantly higher in extrapancreatic necrosis patients than in those with peripancreatic fluid collections (p < 0.001). Among the single indicators, the accuracy of the area of extrapancreatic collections (AUC = 0.871) was comparable to that of the EPIM score for predicting extrapancreatic necrosis and was significantly higher than that of the other two indicators. The combination of all indicators showed the highest predictive accuracy (AUC = 0.949), and combinations of two or more indicators demonstrated significantly higher predictive accuracy for extrapancreatic necrosis than any single indicator (p < 0.05) except for the area of extrapancreatic collections (p > 0.05).

CONCLUSION

The MRI characteristics have the potential to differentiate early extrapancreatic necrosis from peripancreatic fluid collections and help indicate extrapancreatic necrosis.

Outcomes of Endoscopic Management of Sterile Walled-Off Pancreatic Necrosis: A Systematic Review

OBJECTIVES

The aim of this study is to systematically review outcomes related to treatment success, mortality, and adverse events of endoscopic management in patients with sterile walled-off pancreatic necrosis.

METHODS

We reviewed studies published from 2008 to 2018 from Medline and Embase that evaluated the endoscopic treatment of necrotizing pancreatitis. The primary outcome was success of treatment in resolving the collection. Secondary outcomes included length of hospitalization, mortality rate, and adverse events.

RESULTS

Five studies were included, which entailed a total of 280 patients with a mean age of 51.8 years. The primary indication for endoscopic treatment was symptomatic walled-off pancreatic necrosis. Four studies used endoscopic transmural drainage, one of them combining percutaneous drainage and 1 study performed transpapillary drainage. The pooled treatment success was 94.3% with a mean time to resolution of 77.8 days. The mean length of stay was 16.3 days, and mortality rate was 1.3%. The overall adverse event rate was 24.6%, with bleeding the most common adverse event (11%), followed by pancreatic fistula formation (3.4%) and perforation (2.7%).

CONCLUSIONS

Although endoscopic management of sterile pancreatic necrosis has a high rate of treatment success, there is a relatively high rate of adverse events, bleeding being the most common.

The role of the BISAP score in predicting acute pancreatitis severity according to the revised Atlanta classification: a single tertiary care unit experience from Turkey

BACKGROUND/AIMS

In this study, we examine the utility of Bedside Index of Severity in Acute Pancreatitis (BISAP), which is an increasingly more commonly used simple and practical novel scoring system for predicting the prognosis and severity of the disease at presentation.

MATERIALS AND METHODS

Consecutive patients diagnosed with AP between January 2013 and December 2020 were evaluated retrospectively. The AP severity was assessed using the revised Atlanta classification (RAC). BISAP score, demographic characteristics, pancreatitis etiology, pancreatitis history, duration of hospital stay, and mortality rates of the patients were recorded.

RESULTS

A total of 1000 adult patients were included, of whom 589 (58.9%) were female and 411 (41.1%) were male. The mean age in female and male patients was 62.15 ± 17.79 and 58.1 ± 16.33 years, respectively (p >0.05). The most common etiological factor was biliary AP (55.8%), followed by idiopathic AP (23%). Based on RAC, 389 (38.9%), 418 (41.8%), and 193 (19.3%) patients had mild, moderate, and severe AP. Of the 1000 patients, 42 (4.2%) died. Significant predictors of mortality included advanced age (>65 y) (p=0.003), hypertension (p=0.007), and ischemic heart disease (p=0.001). A BISAP score of ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 79.79%, 91.57%, 69.37%, and 94.99%, respectively, for determining SAP patients according to RAC.

CONCLUSION

BISAP is an effective scoring system with a high NPV in predicting the severity of AP in the early course of the disease in a Turkish population.

Compliance with evidence-based clinical guidelines in the management of acute biliary pancreatitis: the MANCTRA-1 study protocol

Despite existing evidence-based practice guidelines for the management of biliary acute pancreatitis (AP), the clinical compliance with recommendations is overall poor. Studies in this field have identified significant discrepancies between evidence-based recommendations and daily clinical practice. The most commonly reported gaps between clinical practice and AP guidelines include the indications for CT scan, need and timing of artificial nutritional support, indications for antibiotics, and surgical/endoscopic management of biliary AP. The MANCTRA-1 (coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis) study is aiming to identify the areas for quality improvement that will require new implementation strategies. The study primary objective is to evaluate which items of the current AP guidelines are commonly disregarded and if they correlate with negative clinical outcomes according to the different clinical presentations of the disease. We attempt to summarize the main areas of sub-optimal care due to the lack of compliance with current guidelines to provide the basis for introducing a number of bundles in AP patients' management to be implemented during the next years. The MANCTRA-1 study is an international multicenter, retrospective cohort study with the purpose to assess the outcomes of patients admitted to hospital with a diagnosis of biliary AP and the compliance of surgeons worldwide to the most up-to-dated international guidelines on biliary AP. ClinicalTrials.Gov ID Number: NCT04747990, Date: February 23, 2021. Protocol Version V2.2.

Plasmatic Oxidative and Metabonomic Profile of Patients with Different Degrees of Biliary Acute Pancreatitis Severity

Acute pancreatitis (AP) is an inflammatory process of the pancreas with variable involvement of the pancreatic and peripancreatic tissues and remote organ systems. The main goal of this study was to evaluate the inflammatory biomarkers, oxidative stress (OS), and plasma metabolome of patients with different degrees of biliary AP severity to improve its prognosis. Twenty-nine patients with biliary AP and 11 healthy controls were enrolled in this study. We analyzed several inflammatory biomarkers, multifactorial scores, reactive oxygen species (ROS), antioxidants defenses, and the plasma metabolome of biliary AP and healthy controls. Hepcidin (1.00), CRP (0.94), and SIRI (0.87) were the most accurate serological biomarkers of AP severity. OS played a pivotal role in the initial phase of AP, with significant changes in ROS and antioxidant defenses relating to AP severity. Phenylalanine (p < 0.05), threonine (p < 0.05), and lipids (p < 0.01) showed significant changes in AP severity. The role of hepcidin and SIRI were confirmed as new prognostic biomarkers of biliary AP. OS appears to have a role in the onset and progression of the AP process. Overall, this study identified several metabolites that may predict the onset and progression of biliary AP severity, constituting the first metabonomic study in the field of biliary AP.

Imaging of inflammatory disease of the pancreas

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

Pancreatic Disorders of Pregnancy

The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.

The role of imaging in acute pancreatitis

Acute pancreatitis is one of the most commonly encountered etiologies in the emergency setting, with a broad spectrum of findings that varies in severity from mild interstitial pancreas to severe forms with significant local and systemic complications that are associated with a substantial degree of morbidity and mortality. In this article the radiological aspect of the terminology and classification of acute pancreatitis are reviewed. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed. The authors present a practical image-rich guide, applying the revised Atlanta classification system, with the goal of facilitating radiologists to write a correct report, and reinforcing the radiologist’s role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. Computed tomography is the most performed imaging test for acute pancreatitis. Nevertheless, MRI is useful in many specific situations, due to its superiority soft tissue contrast resolution and better assessment of biliary and pancreatic duct, for example in the ductal disconnection. The purpose if this article is to review recent advances in imaging acquisition and analytic techniques in the evaluation of AP.

Clinical Evaluation of Acute Pancreatitis Caused by SARS-CoV-2 Virus Infection

Introduction

Coronavirus 2019 disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread to more than 200 countries worldwide. We aimed to present acute pancreatitis (AP) cases caused by SARS-CoV-2 viral infection.

Methods

The study was conducted retrospectively between April 2020 and June 2020 in Necmettin Erbakan University Meram, Medical Faculty Hospital, and 150 hospitalized patients diagnosed with COVID-19 were included. The degree of acute pancreatitis was determined according to the Atlanta classification. Organ failures of the patients were evaluated in terms of respiratory, cardiovascular, and nephrology according to the modified Marshall scoring (MMS) system, and CTSI (Balthazar score) and Imrie score were determined. Modified Marshall score ≥ 2 was considered organ failure.

Results

A total of 29 patients were diagnosed with acute pancreatitis. All 29 patients with pancreatitis had respiratory failure during hospitalization. After the diagnosis of pancreatitis, there was no change in respiratory failure. According to the Atlanta classification, 19 patients had mild AP and 10 patients had moderate AP. Patients with acute pancreatitis were scored according to the CTSI (Balthazar score), and there were no patients with ≥6 severe pancreatitis. The CTSI score of 4 patients was 3. In addition, the Imrie score of the patients was determined and 8 patients with Imrie score ≥ 3 were identified.

Conclusion

The rate of pancreatic damage in SARS-CoV-2 infection was found to be 19% (n = 29) in our study. In our study, we highlight acute pancreatitis as a complication associated with COVID-19 and the importance of pancreatic evaluation in patients with COVID-19 and abdominal pain is demonstrated.

Novel multidisciplinary hub-and-spoke tertiary service for the management of severe acute pancreatitis

OBJECTIVE

Severe acute pancreatitis (SAP) is associated with high mortality (15%-30%). Current guidelines recommend these patients are best managed in a multidisciplinary team setting. This study reports experience in the management of SAP within the UK's first reported hub-and-spoke pancreatitis network.

DESIGN

All patients with SAP referred to the remote care pancreatitis network between 2015 and 2017 were prospectively entered onto a database by a dedicated pancreatitis specialist nurse. Baseline characteristics, aetiology, intensive care unit (ICU) stay, interventions, complications, mortality and follow-up were analysed.

RESULTS

285 patients admitted with SAP to secondary care hospitals during the study period were discussed with the dedicated pancreatitis specialist nurse and referred to the regional service. 83/285 patients (29%; 37 male) were transferred to the specialist centre mainly for drainage of infected pancreatic fluid collections (PFC) in 95% (n=79) of patients. Among the patients transferred; 29 (35%) patients developed multiorgan failure with an inpatient mortality of 14% (n=12/83). The median follow-up was 18.2 months (IQR=11.25-35.51). Multivariate analysis showed that transferred patients had statistically significant longer overall hospital stay (p<0.001) but less ICU stay (p<0.012).

CONCLUSION

This hub-and-spoke model facilitates the management of the majority of patients with SAP in secondary care setting. 29% warranted transfer to our tertiary centre, predominantly for endoscopic drainage of PFCs. An evidence-based approach with a low threshold for transfer to tertiary care centre can result in lower mortality for SAP and fewer days in ICU.

Deutschsprachige Terminologie der revidierten Atlanta-Klassifikation bei akuter Pankreatitis: Glossar basierend auf der aktuellen S3-Leitlinie zur akuten, chronischen und Autoimmunpankreatitis

Die im Jahr 1992 veröffentlichte Atlanta-Klassifikation zur Beurteilung von Schweregraden und Komplikationen der akuten Pankreatitis sollte ursprünglich eine einheitliche Terminologie für Kliniker und Forscher etablieren. Nach einer kontinuierlichen Weiterentwicklung wurde dann 2012 die revidierte Atlanta-Klassifikation publiziert, um die Aspekte der Bildgebung besser zu integrieren sowie Unschärfen in der Terminologie zu optimieren. Diese Begrifflichkeiten bezüglich der Krankheitseinteilung, -phasen, Schweregradbeurteilung und lokaler Komplikationen lagen bisher lediglich als englische Ausdrücke vor. Dies verhinderte eine weitere Verbreitung und Anwendung im klinischen Alltag im deutschsprachigen Raum. Um eine Anpassung in der deutschsprachigen Medizin zu erreichen, wurden die Termini der revidierten Atlanta-Klassifikation durch ein Expertenteam der Deutschen Röntgengesellschaft basierend auf aktueller Literatur übersetzt und im Rahmen der Konsensuskonferenz der neu erstellten S3-Leitlinie Pankreatitis im Februar 2020 mit einer Zustimmung von 97,3 % als Teil der Leitlinienempfehlung angenommen. Im folgenden Text mit Glossar werden die übersetzten und konsentierten Begrifflichkeiten anhand von Bildbeispielen erläutert.

Kernaussagen: 

Accuracy of angiopoietin-2 for predicting organ failure in patients with acute pancreatitis: a systematic review and meta-analysis

OBJECTIVE

Our aim was to assess the accuracy of angiopoietin-2 (Ang-2) as a prognostic marker for acute pancreatitis (AP) with organ failure (OF).

METHODS

We undertook a systematic search of the PubMed, Cochrane Library, Embase, Chinese Journals Full-text, Wanfang, China Biology Medicine disc, and Weipu databases to identify eligible cohort studies on the predictive value of Ang-2 for AP with OF. The main outcome measures were sensitivity and specificity. The effects were pooled using a bivariate mixed-effects model.

RESULTS

Six articles with seven case-control studies (n = 650) were included. Pooled sensitivity, specificity, and positive and negative likelihood ratios with 95% confidence intervals (CI) for AP with OF were 0.93 (95%CI: 0.75-0.99), 0.85 (95%CI: 0.75-0.92), 6.40 (95%CI: 3.36-12.19), and 0.08 (95%CI: 0.02-0.36), respectively. The area under the summary receiver operating characteristic curve was 0.95 (95%CI: 0.92-0.96), and the diagnostic odds ratio was 83.18 (95%CI: 11.50-623.17). Subgroup analysis showed that admission time of AP onset (< or ≥24 hours) was a source of overall heterogeneity. Sensitivity analysis supported this finding.

CONCLUSION

Ang-2 had high diagnostic accuracy for AP with OF; the best prediction of Ang-2 may be 24 to 72 hours after onset of AP.

The Relationship Between Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios With Hospital Stays and Mortality in the Emergency Department

Background Most acute pancreatitis scoring is made in the first 48-72 hours or later. Like many inflammatory processes, Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) can be useful in showing the severity and extent of inflammation in acute pancreatitis. Our study aimed to evaluate whether these rates affect mortality according to the NLR and PLR values ​​of patients diagnosed with acute pancreatitis by examining the blood samples taken within the first hour after admission to the emergency department rates are useful in predicting the length of stay. Methods In our retrospective study, 557 patients applied to our clinic for 4.5 years, whose amylase and lipase values ​​were higher than two times the cut-off value in blood tests and whose CT imaging was compatible with acute pancreatitis were included in the study. Results The median length of hospitalization of the patients was 4.0 (3.0-6.0) days. Gallstones were detected in 320 (57.5%) patients. Mortality of less than a year was observed in 45 (8.1%) of the study population. Eighteen of the patients (3.2%) showed the need for follow-up in the intensive care unit. A statistically significant relationship was found between mortality and variables hematocrit (HCT), red cell distribution width (RDW),c-reactive protein CRP), glucose, urea, potassium, albumin, PLR, and NLR (p <0.05). A statistically significant correlation was observed between RDW, NLR, glucose, and CRP levels in the two groups divided according to the median value of 4 days we found on hospitalization (p <0.05). According to the graphics and test results obtained by ROC analysis, the mortality status can be predicted at a statistically significant level with PLR and NLR diagnostic tests (p <0.05). Conclusion High levels of NLR, PLR, RDW, glucose, CRP, urea, potassium, low albumin and hematocrit values ​​at the first admission in the Emergency Service seem to be associated with increased 1-year mortality in acute pancreatitis.

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

Pancreas-specific deletion of protein kinase D attenuates inflammation, necrosis, and severity of acute pancreatitis

BACKGROUND

Protein kinase D (PKD) family, which includes PKD/PKD1, PKD2, and PKD3, has been increasingly implicated in the regulation of multiple cellular functions and human diseases. We recently reported that pharmacologic inhibition of PKD ameliorated the pathologic responses and severity of pancreatitis. However, to further investigate the importance of PKD family members in pancreatitis, it is necessary to explore the effects of pancreas-specific genetic inhibition of PKD isoform on pathology of pancreatitis.

METHODS

We generated a mouse model (referred as PKD3Δpanc mice) with pancreas-specific deletion of PKD3, the predominant PKD isoform in mouse pancreatic acinar cells, by crossing Pkd3flox/flox mice with Pdx1-Cre transgenic mice which express Cre recombinase under the control of the mouse Pdx1 promoter. Pancreas-specific deletion of the PKD3 gene and PKD3 protein was confirmed by PCR and Western blot analysis. Experimental pancreatitis was induced in PKD3Δpanc and Pkd3flox/flox (control mice) littermates by intraperitoneal injections of cerulein or L-arginine.

RESULTS

Compared to the control mice, PKD3Δpanc mice displayed significant attenuation in inflammation, necrosis, and severity of pancreatitis in both experimental models. PKD3Δpanc mice had markedly decreased NF-κB and trypsinogen activation, pancreatic mRNA expression of multiple inflammatory molecules, and the receptor-interacting protein kinase 1 (RIP1) activation in pancreatitis. PKD3Δpanc mice also had less pancreatic ATP depletion, increased pro-survival Bcl-2 family protein expression, and autophagy promotion.

CONCLUSION

With PKD3Δpanc mouse model, we further demonstrated that PKD plays a critical role in pathobiological process of pancreatitis and PKD constitutes a novel therapeutic target to treat this disorder.

Pancreatic necrosis volume - A new imaging biomarker of acute pancreatitis severity

OBJECTIVE

Determine if the pancreatic necrosis volume (PNV) in computed tomography scan (CT) is a useful marker to predict the severity of acute pancreatitis (AP) comparing its predictive value with current clinical scoring systems.

METHODS

This retrospective study was conducted in a tertiary hospital, including patients hospitalized with AP during the period of 24 months. Demographic, clinical data, length of hospital stay and analytical parameters were collected from the hospital clinical information digital systems. Other information on the severity of the disease was also reviewed, including BISAP score, organ failure (OF) or admission to the ICU, as well as, complications during hospitalization as infected necrotic collections, surgical procedure or death. The quantification of the necrosis volume, CT severity index and Balthazar score were assessed in the CT studies. ROC curves were carried to compare the correlation between different scoring systems and the acute complications.

RESULTS

This study included 163 patients with AP. The calculated average value of PNV in the CT studies was 242 cc (0-1575 cc). PNV showed lineal correlation with hospital stay (Pearson 0.696) and statistically significant association with acute complications as OF, multiple organ failure, infection, need of treatment or hospitalization at ICU (P < 0.05). The optimal cut-off value for predicting complications of necrosis as infections or need of surgery treatments was 75 cc. Sensibility and specificity were 100 % and 78 %, respectively. ROC curves showed that PNV was the best radiological finding correlated with AP complications.

CONCLUSION

Necrosis volume is a radiological biomarker highly correlated with AP complications.

MRI in acute pancreatitis

Computed tomography (CT) is the most commonly performed imaging test for acute pancreatitis. Nevertheless, magnetic resonance (MRI) imaging is useful in many specific situations. These include evaluating patients with acute pancreatitis who cannot receive iodinated CT contrast, elucidating the underlying cause of acute pancreatitis, assessing ductal disconnection and for guiding intervention of necrotic collections. Non-contrast MRI is superior to non-contrast CT and MRI for the diagnosis of acute pancreatitis. We discuss these specific uses of MRI in acute pancreatitis. We highlight the future advances in MRI including faster, free-breathing scans that allow MRI to be completed within 10 min.