Inflammatory Markers of Disease Severity in Acute Pancreatitis

The role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammation index in predicting the necessity for surgery and therapeutic surgery in patients with anterior abdominal stab wounds

BACKGROUND

In this diagnostic accuracy study, we examined the effectiveness of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) in predicting the need for surgical intervention in patients with anterior abdominal stab wounds (AASW) who exhibit unclear findings on physical examination yet remain hemodynamically stable.

METHODS

Over a 7-year period, patients with AASW were retrospectively analyzed. Patients were divided into two groups as surgical (SG) and nonsurgical group (nSG). The SG were also divided into two groups as therapeutic surgery (TS) group and the non-therapeutic surgery (nTS) group. The groups were compared in terms of NLR, PLR values and SII scores.

RESULTS

In a retrospective analysis of 199 patients with AASW, NLR, PLR and SII obtained during clinical follow-up of patients with AASW in whom the necessity for immediate surgery was unclear significantly predicted therapeutic surgery (p < 0.001 for all). These parameters did not show a significant difference in predicting the need for surgery at the admission. NLR showed an AUC of 0.971 and performed significantly better than PLR and SII (AUC = 0.874 and 0.902, respectively) in predicting TS. The optimal cut-off value for NLR was 3.33, with a sensitivity of 98.2%, a specificity of 90%, and a negative likelihood ratio of 0.02. Time from admission to surgery was significantly shorter in the TS group (p = 0.001).

CONCLUSION

NLR, PLR and SII values may be useful in predicting therapeutic surgery during clinical follow-up in AASW patients with unclear physical examination findings and in whom immediate surgical decisions cannot be made.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Treatment and diagnosis of hyperlipidemia acute pancreatitis in pregnancy associated with pre‑pregnancy obesity and diabetes: A case report

Hyperlipidemia acute pancreatitis (HLAP) is a specific type of pancreatitis mainly caused by elevated serum triglyceride (TG) levels. Therefore, knowledge of patients' medical history is crucial to the identification of those at high risk of HLAP. Diabetes and obesity are associated with high levels of triglycerides, a risk factor for the development of HLAP, which should be controlled before pregnancy. Moreover, HLAP is associated with additional diagnostic and management challenges related to hyperlipidemia (HL) and pregnancy. HLAP during pregnancy has a rapid onset and rapid progression, and complications are more likely to damage the function of multiple organs. HLAP is more common after 28 weeks of pregnancy, the cause is mostly high TG and the serum TG of the patient is often >1,000 mg/d1. Clinicians should be alert to the occurrence of server acute pancreatitis (AP). Therefore, clinicians need to identify and implement effective treatment in a timely manner to control the progression of HLAP during pregnancy and improve pregnancy outcomes. The present study reported the case of a 26-year-old pregnant patient who was hospitalized for epigastric pain at 35 weeks and 2 days of gestation. Medical and family history reported previous diagnoses of diabetes and obesity (weight before pregnancy, 103 kg; BMI, 36.40 kg/m2). Laboratory tests demonstrated high levels of lipase and amylase, a notable systemic inflammatory response, HL, coagulopathy, hypoproteinemia and hyperglycemia. Abdominal ultrasonography demonstrated a hypoechoic pancreatic head. A clinical diagnosis of AP was confirmed using CT scanning. Initial interventions for HLAP included aggressive intravenous hydration, bowel rest, pain control and a combination of heparin and insulin. Lipid-lowering agents were administered to reduce serum lipid levels. Hemoperfusion and continuous renal replacement therapy were also used to rapidly counteract the elevated lipid levels. Antibiotics were administered in the present case because inflammatory markers such as leukocytes, neutrophils and C-reactive protein were elevated. The patient and newborn were discharged 11 days after hospitalization, with an improvement in maternal clinical health and the infant was healthy. When evaluating pregnant patients with pre-obesity and diabetes presenting with abdominal pain, obstetricians should consider HLAP. Timely diagnosis and multi-team precision treatment are effective for good outcomes for mother and baby.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Association of Serum Levels of Silent Information Regulator 1 with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Early assessment is a key factor for adequate and comprehensive treatment of acute pancreatitis (AP). Silent information regulator 1 (SIRT1) plays an important role in inflammation. The aim was to explore the relationship between serum SIRT1 and persistent organ failure (POF) in patients with AP.

METHODS

Thirty-seven healthy controls (HCs) and 113 patients with AP were recruited for this study. All 113 patients whose blood samples were collected on the first morning after admission were within 48 h of the onset of AP symptoms. The concentration of serum SIRT1 protein was determined by enzyme-linked immunosorbent assay.

RESULTS

The serum SIRT1 protein levels were 1495.7 ± 185.9, 2098.3 ± 153.6, 2498.4 ± 198.2, and 3674.3 ± 170.8 pg/ml in the HCs, mild AP, moderately severe AP, and severe AP groups, respectively. Obvious differences were observed between HCs and patients with AP (P < 0.05). Significant increases were observed in SIRT1 concentrations in patients with POF compared with non-POF patients (P < 0.05). When the cut-off of the SIRT1 concentration was 4065.4 pg/ml, the serum SIRT1 concentration had an area under the curve (AUC) of the receiver operating characteristic curve of 0.825 (95% CI 0.744-0.906) for predicting POF, with a sensitivity of 61.4% and specificity of 92.8%. Combining serum SIRT1 and bedside index for severity acute pancreatitis (BISAP) achieved 0.931 (95% CI 0.882, 0.980) of AUC for the predication of POF.

CONCLUSIONS

High serum SIRT1 levels may serve as an early predictive marker for POF. Combining the serum SIRT1 concentration with BISAP increased the ability to predict outcomes.

Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points

Background and Aims. This study evaluated the prognostic accuracy of BUN for severe acute pancreatitis (SAP) and in-hospital mortality (IHM) in terms of the best timing for BUN measurement and the optimal BUN cutoff points. Methods. BUN determinants at the time of admission and 24 hrs after hospital admission were recorded and analyzed statistically. The ability of BUN in predicting the SAP and the occurrence of IHM were assessed using the area under the receiver-operating characteristic (ROC) curve. Results. For SAP, AUC of BUN at admission and 24 hrs after hospital admission was 0.75 and 0.80, respectively. For IHM in acute pancreatitis, it was 0.86 at admission and 0.84 after 24 hrs of hospital admission, respectively. The optimal cutoff point of BUN 24 hrs after hospital admission for SAP and at admission for IHM was 8.3 mmol/L and 13.3 mmol/L, respectively. Conclusion. BUN determination after 24 hrs of hospital admission has high accuracy for prediction of SAP while BUN at initial admission has high accuracy for prediction of IHM.

Leptin Is Associated With Persistence of Hyperglycemia in Acute Pancreatitis: A Prospective Clinical Study

Adipokines have many homeostatic roles, including modulation of glucose metabolism, but their role in the pathophysiology of hyperglycemia associated with acute and critical illnesses in general, and acute pancreatitis (AP) in particular, is largely unknown. This study aimed to investigate the relationship between a panel of adipokines and hyperglycemia in the early course of AP, as well as the role of adipokines as predictors of AP severity.Adiponectin, leptin, omentin, resistin, and visfatin were measured on a daily basis in the first 72 hours after hospital admission. A first set of analyses was undertaken with admission glycemia stratified by severity, and a second set of analyses was undertaken based on persistence of early hyperglycemia. All of the analyses were adjusted for confounders.A total of 32 patients with AP were included in this study. None of the studied adipokines was significantly associated with glucose level on admission. Leptin was significantly (P = 0.003) increased in patients with persistent hyperglycemia. Adiponectin was significantly associated with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in patients with persistent hyperglycemia (P = 0.015), visfatin with APACHE II score in patients with persistent hyperglycemia (P = 0.014), and omentin with APACHE II score in all of the patients regardless of the presence or absence of hyperglycemia (P = 0.021).Leptin is significantly associated with persistent hyperglycemia in the early course of AP. Omentin has a potential to become an accurate predictor of AP severity.

Antibiosis of Necrotizing Pancreatitis

BACKGROUND

Necrotizing pancreatitis is a life-threatening presentation of acute pancreatitis. The mortality of 20-80% initially depends on the persistence of organ failure and systemic inflammatory response syndrome (SIRS) and, in the later course of the disease, on secondary infection of the necrosis. The questions whether prophylactic antibiotics aiming to prevent this infection should be administered and which antibiotic is the best to use, as well as the problem of fungal infection under antibiotic treatment are still intriguing and insufficiently solved.

METHODS

A search of the literature using PubMed was carried out, supplemented by a review of the programmes of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW).

RESULTS

Despite the widely practised prophylactic antibiotic administration in severe pancreatitis, no evidence for the benefit of this strategy exists. One of the drawbacks might be a tendency for disastrous fungal infection under prophylactic antibiotics. Bacterial translocation from the gut in the second week after the onset of symptoms is the major source for infection of pancreatic necrosis and provides a clear indication for antibiotic treatment. However, routine fine-needle aspiration for a calculated antibiotic therapy cannot be recommended, and all other tests offer only indirect signs. Important factors such as enteral versus parenteral feeding and the method of necrosectomy are mostly neglected in the trials but seem to be essential for the outcome of the patient.

CONCLUSIONS

Even though most meta-analyses including the newer double-blind, placebo-controlled trials on prophylactic antibiotics showed no beneficial effects in the prevention of infection of necrosis and/or outcome of the patients, this strategy is still widely used in clinical routine. Since nearly all trials published so far show systematic problems (i.e. inaccurate definition of the severity of the disease, poor statistical testing, and neglect of differences in the route of nutrition), there is a need for randomized controlled prospective trials with exact definitions of the disease.

High phosphate serum levels correlate with the severity of experimental severe acute pancreatitis: insight into the purinergic system

OBJECTIVES

Extracellular purines are a component of the systemic inflammatory response, and their levels are modulated by ectonucleotidases. In addition, nucleotide hydrolysis releases phosphate. We studied serum phosphate levels as a predictor of severity in acute pancreatitis (AP) and their correlation with extracellular purinergic metabolism.

METHODS

Acute pancreatitis was induced by the retrograde injection of sodium taurocholate. The AP group was compared with animals submitted to a model of sepsis by cecal ligation and puncture. The sham group was submitted to laparotomy and closure. We measured the phosphate and purine levels in serum and the expression of 5'-nucleotidase (CD73) and the adenosine A2a receptor in pancreatic tissue by quantitative real-time polymerase chain reaction.

RESULTS

Serum phosphate levels were higher in severe AP and correlated with severity. Severe AP led to increased serum levels of adenosine diphosphate, adenosine monophosphate, and adenosine. In addition, adenosine monophosphate conversion to adenosine in serum was accelerated in the AP groups. We found a positive correlation between serum adenosine and phosphate in the AP groups. The expression levels of CD73 and the adenosine A2a receptor in the pancreas were not altered.

CONCLUSIONS

Our study suggests that serum phosphate correlates with severity in AP and implicates extracellular purines in the systemic response to severe AP.

Increased interleukin-23/17 axis and C-reactive protein are associated with severity of acute pancreatitis in patients

OBJECTIVE

The interleukin (IL)-23/IL-17 axis plays an important role in various inflammatory conditions but its function in acute pancreatitis (AP) is not well understood. The present study investigated the relationship between serum levels of IL-23, IL-17, and C-reactive protein (CRP) in patients and the severity of AP.

METHODS

Eighty-five patients with AP were categorized into mild group, moderately severe group, and severe group according to the revised Atlanta classification, 2012. Serum levels of IL-23 and IL-17 were measured by enzyme-linked immunosorbent assay in patients 48 hours after admission. The CRP levels of patients were also measured on admission and 48 hours after admission.

RESULTS

The serum levels of CRP of patients on admission and 48 hours after admission and levels of IL-23 and IL-17 of patients 48 hours after admission increased alone with the severity of AP, respectively (P < 0.01). The serum levels of IL-23 and IL-17 in the patients were correlated with CRP levels (r = 0.234, r = 0.552, P < 0.001, respectively).

CONCLUSIONS

The serum levels of IL-17, IL-23, and CRP are correlated with the severity of AP and represent valuable prognostic factors in the assessment of disease severity of patients with AP.

Serum profiles of M30, M65 and interleukin-17 compared with C-reactive protein in patients with mild and severe acute pancreatitis

BACKGROUND

Several studies state that a test of severity early in the course of acute pancreatitis is still needed. In this prospective study, an assay of the biomarkers M30 and M65 as well as of interleukin 17 (IL-17) is investigated.

METHODS

One hundred and fifty patients and 70 controls were evaluated. The prognostic value of M30, M65 and their ratio M30/M65 is assessed by ELISA. The same method is used for the study of IL-17.

RESULTS

At 24 h after symptom onset, the concentrations of M30 and M65 as well as their ratio, differed significantly in severe compared to mild disease (P = 0.016). C-reactive protein (CRP) was significantly higher (P < 0.001) in severe pancreatitis on the same day. The sensitivity of M65 to show severe acute pancreatitis at 24 h was 100% for values above the cut-off point of 428.15 U/l. The sensitivity of CRP was 100% as well. Concerning IL-17, its concentrations were higher in patients than in the control group (P < 0.001) in the first 24 h.

CONCLUSIONS

Plasma concentrations of M65 and the M30/M65 ratio can be useful in predicting the severity of acute pancreatitis as early as 24 h after the onset of symptoms. The rates of IL-17 early in the course of acute pancreatitis are indicative of the disease.

American College of Gastroenterology guideline: management of acute pancreatitis

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

Fractalkine as a marker for assessment of severe acute pancreatitis

OBJECTIVE

The aim of this study was to study the role of fractalkine (FKN) in the development of severe acute pancreatitis (SAP) in animal model.

METHODS

Serum FKN levels in rat model (control, SAP6 h, 16 h, 24 h and 48 h) were determined by enzyme-linked immunosorbent assay. FKN mRNA and protein levels in the pancreas tissue were measured by reverse transcription polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry.

RESULTS

Serum FKN level in the SAP rat increased significantly (P < 0.05 compared with the control group). FKN mRNA and protein levels in pancreas and lung increased significantly and reached the peak at 16 h after the induction of SAP, while those in kidney reached the peak at 48 h. Immunohistochemistry showed the overexpression of FKN in pancreas, lung and kidney tissue.

CONCLUSION

FKN involves in the progression of SAP and might be a valuable marker for the assessment of SAP.

Recent progress in understanding the pathogenesis of severe acute pancreatitis

Severe acute pancreatitis (SAP) is an acute abdominal disease that is characterized by sudden onset, quick progression, many complications and high mortality. Multiple organ dysfunction syndrome (MODS) is still regarded as the main cause of death in SAP patients. Nowadays, the mortality rate for patients with SAP in developed countries is 22.7%. In the early 21st century, the mortality reached 15.60%-23.77% in mainland China. However, the etiology, pathogenesis and pathophysiology of SAP remains unclear, resulting in puzzle or perplexity in choosing and developing treatment strategies for SAP. This paper reviews recent progress in understanding the pathogenesis of SAP.

Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis

BACKGROUND & AIMS

Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. We performed a randomized controlled trial to evaluate the impact of a goal-directed fluid resuscitation protocol on systemic inflammation in patients with acute pancreatitis. We then determined the impact of resuscitation with lactated Ringer's solution, compared with normal saline.

METHODS

We performed a randomized controlled trial of 40 patients with acute pancreatitis at 3 New England hospitals from May 2009-February 2010. Patients received goal-directed fluid resuscitation with lactated Ringer's solution, goal-directed fluid resuscitation with normal saline, standard fluid resuscitation with lactated Ringer's solution, or standard fluid resuscitation with normal saline. Systemic inflammation was measured on the basis of levels of systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) level after 24 hours.

RESULTS

The volumes of fluid administered during a 24-hour period were similar among patients given goal-directed or standard fluid resuscitation (mean, 4300 vs 4600 mL, respectively; P = .87). Goal-directed resuscitation did not significantly reduce incidence of SIRS, compared with standard resuscitation (11.8% vs 13.0%, respectively; P = .85) or levels of CRP after 24 hours (87.1 vs 69.2 mg/dL, respectively; P = .75). By contrast, there was a significant reduction in SIRS after 24 hours among subjects resuscitated with lactated Ringer's solution, compared with normal saline (84% reduction vs 0%, respectively; P = .035); administration of lactated Ringer's solution also reduced levels of CRP, compared with normal saline (51.5 vs 104 mg/dL, respectively; P = .02).

CONCLUSIONS

Patients with acute pancreatitis who were resuscitated with lactated Ringer's solution had reduced systemic inflammation compared with those who received saline.

New prognostic markers for outcome of acute pancreatitis: overview of reporting in 184 studies

OBJECTIVES

The objective of this study was to assess the reporting of studies on new prognostic markers of outcome in acute pancreatitis.

METHODS

We used MEDLINE searches complemented with perusal of review articles' references to identify eligible English-language studies. We included studies evaluating nonroutine markers for acute pancreatitis. Eligible outcomes included Atlanta criteria, Japanese criteria for severity, multiple/single organ failure, complications, interventional treatment, hospitalization length, and death. We generated a 47-item checklist on Acute Pancreatitis Prognosis by adapting a previously constructed reporting guidance instrument for prognostic tumor markers (REMARK [Reporting Recommendations for Tumor Marker Prognostic Studies]). The checklist addresses the reporting of essential information in prognostic studies.

RESULTS

The 184 identified eligible studies reported on 196 different prognostic markers. One hundred forty-four studies (78.3%) found at least 1 prognostic marker to be nominally statistically significant. Significant improvements over time were seen in the reporting for 17 items, but major deficiencies were noted even in 2004-2009 studies. Particularly, 12 items were reported in less than 10% of studies overall and even within the most recent studies.

CONCLUSIONS

Despite some improvements over time, the reporting of important aspects of prognostic studies in acute pancreatitis remains suboptimal. The proposed REMARK-based checklist may help improve the quality and reporting of research in this field.

[Effects of gadolinium chloride on sodium taurocholate-induced pancreatitis in rats]

OBJECTIVE

To evaluate the effects of the use of gadolinium chloride before and after induction of acute pancreatitis with sodium taurocholate 3% in rats.

METHODS

Wistar rats were divided into five groups: SF--control with saline intra-ductal and IV; GD control with saline intra-ductal and gadolinium chloride IV; TS--with AP control induced by sodium taurocholate 3% and saline IV; GDTS--pre-treatment with GD (24 hours before the induction of AP) and TSGD--treatment with GD (1 hour after the induction of AP). Analysis was made in serum amylase, transaminases and TNF-α; determination of the MPO activity in lung tissue, lung and pancreatic histology.

RESULTS

The number of dead animals before the end of the experiment was significantly higher in TSGD (P = 0.046). The scores of pancreatitis and lung damage were higher in the groups that used sodium taurocholate compared to groups with intra-ductal infusion of saline solution. There were no differences in other variables studied when comparing TS, GDTS and TSGD groups.

CONCLUSION

The benefits with the use of gadolinium chloride as a prophylactic and therapeutic drug were not demonstrated.

Early hemoconcentration is associated with pancreatic necrosis only among transferred patients

OBJECTIVES

Studies evaluating hemoconcentration as a marker of necrosis in acute pancreatitis have reached different conclusions. The aim of this study was to determine the impact of transfer status on the accuracy of hemoconcentration for the prediction of pancreatic necrosis.

METHODS

We prospectively enrolled 339 patients in an observational cohort study from June 2005 to December 2007. Univariate and multivariate logistic regression analyses were used to evaluate the impact of transfer status on the relationship between hemoconcentration and necrosis. Accuracy for prediction of necrosis was measured by the area under the receiver operating characteristic curve.

RESULTS

Hemoconcentration was associated with increased risk of necrosis only among transferred patients (odds ratio [95% confidence limits], 3.6 [1.2, 10.8]). The area under the receiver operating characteristic curve for admission hematocrit for prediction of necrosis was 0.78 among the transferred patients versus 0.55 among those with primary admissions (chi2, P < 0.0001). Transferred patients had greater initial severity (median bedside index of severity in acute pancreatitis, 2 vs 1; P < 0.0001), were more likely to have hemoconcentration (44% vs 18%; chi2, P < 0.0001), and experienced increased necrosis (37.5% vs 3.6%; chi2, P < 0.0001) compared with primary admissions. After adjusting for sex, disease severity, fluid resuscitation, and transfer status, hemoconcentration was not associated with necrosis (Wald chi2, P = 0.14).

CONCLUSIONS

Transfer status is a confounder in the relationship between hemoconcentration and pancreatic necrosis.

Serum profiles of C-reactive protein, interleukin-8, and tumor necrosis factor-alpha in patients with acute pancreatitis

Background-Aims. Early prediction of the severity of acute pancreatitis would lead to prompt intensive treatment resulting in improvement of the outcome. The present study investigated the use of C-reactive protein (CRP), interleukin IL-8 and tumor necrosis factor-α (TNF-α) as prognosticators of the severity of the disease. Methods. Twenty-six patients with acute pancreatitis were studied. Patients with APACHE II score of 9 or more formed the severe group, while the mild group consisted of patients with APACHE II score of less than 9. Serum samples for measurement of CRP, IL-8 and TNF-α were collected on the day of admission and additionally on the 2nd, 3rd and 7th days. Results. Significantly higher levels of IL-8 were found in patients with severe acute pancreatitis compared to those with mild disease especially at the 2nd and 3rd days (P = .001 and P = .014, resp.). No significant difference for CRP and TNF-α was observed between the two groups. The optimal cut-offs for IL-8 in order to discriminate severe from mild disease at the 2nd and 3rd days were 25.4 pg/mL and 14.5 pg/mL, respectively. Conclusions. IL-8 in early phase of acute pancreatitis is superior marker compared to CRP and TNF-α for distinguishing patients with severe disease.

Early changes in blood urea nitrogen predict mortality in acute pancreatitis

BACKGROUND & AIMS

Routine laboratory tests that reflect intravascular volume status can play an important role in the early assessment of acute pancreatitis (AP). The objective of this study was to evaluate accuracy of serial blood urea nitrogen (BUN) versus serial hemoglobin (Hgb) measurement for prediction of in-hospital mortality in AP.

METHODS

We performed an observational cohort study on data from 69 US hospitals from January 2003 to December 2006. Repeated measures analysis was used to examine the relationship between early trends in BUN and Hgb with respect to mortality. Multivariate logistic regression was used to evaluate the impact of admission BUN, change in BUN, admission Hgb, and change in Hgb on mortality. Time-specific receiver operating characteristic curves and multivariable logistic regression compared accuracy of BUN, Hgb, and additional routine laboratory tests.

RESULTS

BUN levels were persistently higher among nonsurvivors than survivors during the first 48 hours of hospitalization (F-test; P < .0001). No such relationship existed for Hgb (F-test; P = .33). For every 5-mg/dl increase in BUN during the first 24 hours, the age- and gender-adjusted odds ratio for mortality increased by 2.2 (95% confidence limits, 1.8, 2.7). Of the 6 routine laboratory tests examined, BUN yielded the highest area under the concentration-time curve (AUC) for predicting mortality at admission (AUC = 0.79), 24 hours (AUC = 0.89), and 48 hours (AUC = 0.90). Combining admission BUN and change in BUN at 24 hours produced an AUC of 0.91 for mortality.

CONCLUSION

In a large, hospital-based cohort study, we identified serial BUN measurement as the most valuable single routine laboratory test for predicting mortality in AP.

Protease activation, pancreatic leakage, and inflammation in acute pancreatitis: differences between mild and severe cases and changes over the first three days

BACKGROUND/AIMS

The pathophysiology of acute pancreatitis (AP) may be studied using markers of protease activation (active carboxypeptidase B (aCAP), the activation peptide of carboxypeptidase B (CAPAP)), leakage of pancreatic enzymes (trypsinogen-2, procarboxypeptidase B (proCAP), amylase), and inflammation (monocyte chemoattractant protein-1 (MCP-1), CRP).

METHODS

This prospective study included 140 cases of AP. Mild (n = 124) and severe (n = 16) cases were compared with respect to serum levels of trypsinogen-2, proCAP, amylase, aCAP, CAPAP (serum/urine), MCP-1 (serum/urine) and CRP on days 1, 2 and 3 from onset of symptoms. All patients with information on all 3 days were included in a time-course analysis (n = 44-55, except amylase: n = 27).

RESULTS

High levels in severe versus mild cases were seen for trypsinogen-2, CAPAP in serum and urine, and MCP-1 in serum on days 1-3. No differences were seen for proCAP, amylase and aCAP. MCP-1 in urine was significantly elevated on day 1-2, and CRP on day 2-3. CAPAP and MCP-1 levels peaked early and stayed elevated for 48 h in serum.

CONCLUSION

Protease activation and inflammation are early events in AP, with high levels of these markers within 24 h. Protease activation declines after 48 h, whereas inflammation is present for a longer time.

Acute pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas. Acute abdominal pain is the most common symptom, and increased concentrations of serum amylase and lipase confirm the diagnosis. Pancreatic injury is mild in 80% of patients, who recover without complications. The remaining patients have a severe disease with local and systemic complications. Gallstone migration into the common bile duct and alcohol abuse are the most frequent causes of pancreatitis in adults. About 15-25% of pancreatitis episodes are of unknown origin. Treatment of mild disease is supportive, but severe episodes need management by a multidisciplinary team including gastroenterologists, interventional radiologists, intensivists, and surgeons. Improved understanding of pathophysiology and better assessments of disease severity should ameliorate the management and outcome of this complex disease.

A child with abdominal pain and hyperglycemia: is it diabetic ketoacidosis?

Hyperglycemia, abdominal pain, and vomiting are the most common manifestations of diabetic ketoacidosis in pediatric patients. The absence of ketonemia in these patients should prompt a consideration of acute pancreatitis. We report a case of an 11-year-old girl with acute necrotizing pancreatitis, who was initially diagnosed as having new onset diabetes with nonketotic hyperglycemia.

Nutritional immunomodulation of acute pancreatitis

Despite the great advances in our understanding of the pathophysiology of acute pancreatitis, no specific therapy has emerged, and treatment remains supportive. In patients with the severe form of the disease, in which mortality remains high at 20% to 30%, the function of the upper gastrointestinal tract is disturbed due to extrinsic compression by the inflamed and swollen pancreas, and normal eating is impossible. Such patients often develop multiple organ failure, necessitating intensive-care management and artificial ventilation for weeks on end. In this setting, protein catabolism will rapidly result in protein deficiency and further complications unless nutritional support is commenced. Recent studies have shown that, despite the risk of disease exacerbation through pancreatic stimulation, enteral feeding is more effective than parenteral feeding in improving outcome. Experimental studies suggest that this can be attributed to its content of specific immunomodulating nutrients, such as glutamine, arginine, and n-3 fatty acids, and by its stabilizing effect on the gut flora through the provision of prebiotics. Further studies are indicated to examine whether dietary enrichment with these substrates, along with regulation of the gut bacteria with probiotics, can improve outcome further.

Extrapancreatic inflammation on abdominal computed tomography as an early predictor of disease severity in acute pancreatitis: evaluation of a new scoring system

OBJECTIVE

To introduce a new scoring system based on signs of systemic inflammation on computed tomography (CT) [ExtraPancreatic Inflammation on CT (EPIC) score] and evaluate this score as an early prognostic tool.

METHODS

Forty patients with acute pancreatitis who received an abdominal CT within 24 h after admission were included in the study. The Balthazar score, the CT Severity Index, and the EPIC score (based on the presence of pleural effusion, ascites, and retroperitoneal fluid collections) were calculated for all patients. The end points were the occurrence of severe acute pancreatitis (local complication or presence of organ failure for more than 48 h) and in hospital mortality. This score was evaluated by calculating receiver operator characteristic (ROC) curves and the area under the ROC curve.

RESULTS

Mean age of the patients was 50 (+/-17.7) years, and Ranson score was 3.3. Fourteen (35%) patients developed severe disease; in hospital mortality was 15% (6/40). The mean EPIC score was 3.6 (+/-2.0). The area under the ROC curve for predicting severe disease and mortality was 0.91 (95% confidence interval, 0.83-0.99) and 0.85 (95% confidence interval, 0.71-0.99), respectively. An EPIC score of 4 or more had a 100% sensitivity and 70.8% specificity for predicting severe pancreatitis. The EPIC score was superior to the Balthazar score and CT Severity Index to predict outcome.

CONCLUSIONS

In patients with acute pancreatitis, extrapancreatic inflammation assessed by abdominal CT scan and quantified with the EPIC score allows accurate estimation of disease severity and mortality within 24 h of admission.

Effects of continuous high-volume hemofiltration on experimental severe acute pancreatitis in pigs

OBJECTIVE

To compare the effects of different doses of hemofiltration on severe acute pancreatitis (SAP) in pigs.

METHODS

The animal model of SAP was produced by intraductal injection of sodium taurocholate and trypsin. Animals in group 1 served as SAP control. Animals in group 2 received (20 mL/kg per hour) continuous low-volume hemofiltration (LVHF), and animals in group 3 received (100 mL/kg per hour) continuous high-volume hemofiltration (HVHF) immediately after the induction of SAP. After the instrumentation of the animals by arterial and Swan-Ganz catheters, hemodynamic indexes were monitored intermittently at different times. The rectal temperature and the concentration of amylase and cytokines in serum were measured at the same time.

RESULTS

The survival time of HVHF group was significantly prolonged (P < 0.01). The initial elevation of body temperature and the hypothermia in the late course of experiments were significantly ameliorated by HVHF (P < 0.01). Six hours after the induction of pancreatitis, the urine output of animals in HVHF group was obviously higher than that in control group (P < 0.05), which stayed behind 36 hours later (P < 0.05). The major hemodynamic finding was that pancreatitis-induced hypotension was significantly attenuated by HVHF (P < 0.01). The development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increase in CI, an attenuated decrease in systemic vascular resistance index. Plasma amylases in the HVHF group were significantly lower than those in control and LVHF groups (P < 0.01). The serum concentrations of cytokines such as tumor necrosis factor alpha (TNF-alpha), interleukin (IL) 6, and IL-10 all decreased significantly in treatment groups (P < 0.01), and those of HVHF group were less significant than the HVHF group (P < 0.01).

CONCLUSIONS

The HVHF was associated with a better hemodynamic profile, a less hyperkinetic state, and more prolonged survival than that of LVHF, which may result from the HVHF that can remove the inflammatory cytokines more efficiently.

Does serum procalcitonin have a role in evaluating the severity of acute pancreatitis? A question revisited

PURPOSE

This study was designed to evaluate the diagnostic accuracy of serum procalcitonin (PCT) for the diagnosis of severity in acute pancreatitis (AP), compared with routine clinical, biochemical, radiological, and combination severity scoring systems.

METHODS

Quantitative meta-analysis was performed on prospective studies, comparing serum PCT, against validated scoring systems for diagnosing severe AP. The sensitivity, specificity, and diagnostic odds ratio were calculated for each study. Summary receiver operating characteristic (SROC) curves and subgroup analysis were undertaken. Study quality and heterogeneity were evaluated. Meta-regression meta-analysis was used to evaluate the effect of using serum PCT in the diagnostic accuracy severity scoring in AP.

RESULTS

Summary receiver operating characteristic analysis of nine studies showed an overall sensitivity and specificity of 74% (range: 66%-81%) and 83% (range: 79%-87%), respectively. Overall unweighted area under the curve (AUC) was 0.91 (DOR = 16.26 95% CI: 5.68-46.60), demonstrating significant heterogeneity (Q-value = 25.32; P = 0.001). When high-quality studies alone were evaluated, there was an increase in the overall sensitivity (89%); however, specificity was similar (82%), with an overall unweighted AUC of 0.94 (DOR 41.46, 95% CI: 17.95-95.80), with no significant heterogeneity. Meta-regression analysis confirmed the significant effect of study quality on the diagnostic accuracy of severity scoring using serum PCT (P = 0.025).

CONCLUSIONS

The use of PCT for severity scoring in AP has a moderate sensitivity but higher specificity. However, the overall accuracy for predicting severity in AP is high. The prognosis of severity, especially early on (<48 hours from onset of symptoms), and the evaluation of potential infectious complications of AP may be the most useful factors to assess in subsequent clinical trials to identify its exact application in clinical practice in the management of AP.

Dexamethasone mediates protection against acute pancreatitis via upregulation of pancreatitis-associated proteins

AIM

To examine the influence of dexamethasone on pancreatitis-associated protein (PAP) gene expression using both in vitro and in vivo models of acute pancreatitis and to study how PAP gene expression correlates with severity of pancreatitis.

METHODS

In vitro, IL-6 stimulated pancreas acinar AR42J cells were cultured with increasing concentrations of dexamethasone and assayed for PAP expression (RT-PCR). In vivo, pancreatitis was induced in rats by retrograde injection of 40 g/L taurocholate into the pancreatic duct. Animals were pretreated with dexamethasone (2 mg/kg) daily or saline for 4 d. Pancreata and serum were harvested after 24 h and gene expression levels of PAP I, II and III were measured by RT-PCR. Severity of pancreatitis was based on serum amylase, pancreatic wet weight, and histopathological score.

RESULTS

In vitro, dexamethasone and IL-6 induced a marked transcription of PAP I, II and III genes in AR42J cells at 24 h (P < 0.05 for all comparisons). In vivo, pancreas mRNA levels of PAP I, II or III increased by 2.6-fold, 1.9-fold, and 1.3-fold respectively after dexamethasone treatment, compared with saline treated animals. Serum amylase levels and edema were significantly lower in the dexamethasone group compared with the saline group. Histopathologic evaluation revealed less inflammation and necrosis in pancreata obtained from dexamethasone treated animals (P < 0.05).

CONCLUSION

Dexamethasone significantly decreases the severity of pancreatitis. The protective mechanism of dexamethasone may be via upregulating PAP gene expression during injury.

Biochemical markers of acute pancreatitis

Serum amylase remains the most commonly used biochemical marker for the diagnosis of acute pancreatitis, but its sensitivity can be reduced by late presentation, hypertriglyceridaemia, and chronic alcoholism. Urinary trypsinogen-2 is convenient, of comparable diagnostic accuracy, and provides greater (99%) negative predictive value. Early prediction of the severity of acute pancreatitis can be made by well validated scoring systems at 48 hours, but the novel serum markers procalcitonin and interleukin 6 allow earlier prediction (12 to 24 hours after admission). Serum alanine transaminase >150 IU/l and jaundice suggest a gallstone aetiology, requiring endoscopic retrograde cholangiopancreatography. For obscure aetiologies, serum calcium and triglycerides should be measured. Genetic polymorphisms may play an important role in "idiopathic" acute recurrent pancreatitis.