Prospective evaluation of the aetiological profile of acute pancreatitis in young adult patients

Association of Serum Endocannabinoid Levels with Pancreatitis and Pancreatitis-Related Pain

Background and Aims: This investigation examined the association of pancreatitis and pancreatitis-related pain with serum levels of two endocannabinoid molecules such as anandamide (AEA) and 2-arachidonoylglycerol (2-AG) and two paracannabinoid molecules such as oleoylethanolamide (OEA) and palmitoylethanolamide (PEA). Methods: A case-control study was conducted within the Prospective Evaluation of Chronic Pancreatitis for Epidemiological and Translational Studies, including participants with no pancreas disease (N = 56), chronic abdominal pain of suspected pancreatic origin or indeterminate chronic pancreatitis (CP) (N = 22), acute pancreatitis (N = 33), recurrent acute pancreatitis (N = 57), and definite CP (N = 63). Results: Circulating AEA concentrations were higher in women than in men (p = 0.0499), and PEA concentrations were higher in obese participants than those who were underweight/normal or overweight (p = 0.003). Asymptomatic controls with no pancreatic disease had significantly (p = 0.03) lower concentrations of AEA compared with all disease groups combined. The highest concentrations of AEA were observed in participants with acute pancreatitis, followed by those with recurrent acute pancreatitis, chronic abdominal pain/indeterminant CP, and definite CP. Participants with pancreatitis reporting abdominal pain in the past year had significantly (p = 0.04) higher concentrations of AEA compared with asymptomatic controls. Levels of 2-AG were significantly lower (p = 0.02) among participants reporting abdominal pain in the past week, and pain intensity was inversely associated with concentrations of 2-AG and OEA. Conclusions: Endocannabinoid levels may be associated with stage of pancreatitis, perhaps through activation of the CB1 receptor. Validation of our findings would support the investigation of novel therapeutics, including cannabinoid receptor-1 antagonists, in this patient population.

Risk Factors of Acute Pancreatitis in Young Adults: A Nationwide Population-Based Cohort Study in South Korea

OBJECTIVES

This study aimed to identify the risk factors for acute pancreatitis (AP) in young adults in their 20s based on data from the nationwide cohort in South Korea.

MATERIALS AND METHODS

From the 2009 national health examination database of South Korea, a total of 471,098 individuals between the ages of 20 and 29 were analyzed. To identify the newly developed AP, the linked claims database was used.

RESULTS

The incidence rates of AP were 18.8 and 9.8 per 100,000 person-years in male and female participants, respectively. Alcohol consumption and smoking were associated with the heightened risk of AP. The risk of AP development was increased as daily alcohol consumption increased. In addition, ex-smokers and current smokers showed higher AP risk than never smokers. Hypertriglyceridemia and obesity were associated with the increased AP risk as well. Compared with female participants, male participants showed a higher risk of AP in univariate analysis but showed a lower risk of AP in multivariate analysis.

CONCLUSIONS

In the young adult population, alcohol consumption, smoking, hypertriglyceridemia, and obesity were associated with an elevated risk of developing AP. It is important to identify and manage the modifiable AP risk factors in young adults to minimize the socioeconomic burden of AP.

Acute pancreatitis as a rare adverse event among cannabis users: A systematic review

BACKGROUND

Cannabis use has been steadily rising in the United States and can have multiple adverse effects, including cannabis-induced acute pancreatitis. This study aims to collate and highlight the significant demographics, clinical presentation, and outcomes in patients with cannabis-induced acute pancreatitis.

METHOD

A systematic literature search of electronic databases for peer-reviewed articles was conducted. After an initial search, we found 792 articles through different electronic databases. After manually removing duplicates and articles that did not meet the criteria, 25 articles were included in our review.

RESULTS

A total of 45 patients were studied, 35 (78%) cases were male and 10 (22%) cases were female, showing male predominance. The mean age of all participants was 29.2 ± 10.3 years. The most common presenting symptoms were abdominal pain 21 of 21 (100%), nausea 17 of 21 (81%), and vomiting 12 of 20 (60%). Ultrasound was normal in the majority of patients, with findings of mild pancreatitis. Computerized tomography scans revealed pancreatic edema and inflammation in 7 of 20 (35%) patients, and findings of necrotizing pancreatitis and complex fluid collection were visualized in 3 of 20 (15%) patients. Dilatation of intrahepatic or extrahepatic biliary ducts was not seen in any patients. The overall prognosis was good, with reported full recovery.

CONCLUSIONS

Cannabis should be included in the differential diagnosis for the etiology of acute pancreatitis, which would help in early intervention and treatment for the mitigation of the rapidly progressive disease.

Cannabinoid-Related Acute Pancreatitis: An Update from International Literature and Individual Case Safety Reports

INTRODUCTION

In addition to the growing interest of different cannabinoids for therapeutic purposes, the safety profile of these substances has changed, with the recent identification of new events such as acute pancreatitis.

OBJECTIVE

The aim of this study was to characterize cannabinoid-related acute pancreatitis, based on the recent literature and the analysis of pharmacovigilance data available worldwide.

METHODS

Nine national and international pharmacovigilance databases were requested for individual case safety reports of acute pancreatitis related to cannabinoid exposure. A systematic review was performed searching in PubMed^®, Web of Science^®, and Google Scholar^® for any publication dealing with acute pancreatitis and cannabinoid exposure (cannabis, cannabinoid, cannabidiol, tetrahydrocannabinol, nabilone, dronabinol), to identify case reports, observational studies, clinical trials, or reviews. All queries were updated on 1 January, 2021.

RESULTS

Twenty-two individual case safety reports were identified in the pharmacovigilance databases and 51 in the literature, corresponding to a predominantly young male population (74% of men, median age 28 interquartile range [21-39]) using recreational Cannabis sativa with high intensity. A therapeutic purpose was identified in 13 cases (including tetrahydrocannabinol, cannabidiol, and dronabinol). The outcome was often favorable after dechallenge (except three deaths), and frequent recurrences were observed in the case of rechallenge or sustained consumption. Eleven cross-sectional studies and one ecological study showed an increasing trend of cannabis use in in-patients with acute pancreatitis, with a significantly lower in-hospital mortality.

CONCLUSIONS

This review underlines that acute pancreatitis is a potential adverse effect of cannabinoid use. It remains often unrecognized and can occur during recreational or therapeutic use. The development of the therapeutic use of cannabinoids in frail patients deserves a better investigation of the benefit-risk ratio of these different products.

Cannabis-Induced Pancreatitis in a Young Adult Male

Drugs account for 2% of all the causes of acute pancreatitis. To date, there are approximately 26 reported cases of acute pancreatitis associated with the use of cannabis. We report the case of a 20-year-old male who presented with intractable nausea, vomiting, and epigastric pain and a lipase level of 1541 with reportedly no alcohol use, and no evidence of medication, biliary, or autoimmune etiology. However, the patient did endorse heavily smoking cannabis prior to symptom onset. He was instructed to abstain from cannabis use on discharge and has not presented to the hospital since this episode. The reporting of this case aims to increase awareness of cannabis as a differential diagnosis in cases of pancreatitis that is not due to typical etiologies such as gallstones, medications, and alcohol use. There has yet to be definitive evidence as to how cannabis can cause pancreatitis. Further studies must be conducted to better understand the association between cannabis use and acute pancreatitis and the mechanism by which cannabis affects the pancreas.

Acute and Severe Acute Pancreatitis and the Effect of Cannabis in States Before and After Legalization Compared With States Without Legalized Cannabis

OBJECTIVES

Cannabis legalization has increased its use. The incidence of acute pancreatitis (AP) and severe acute pancreatitis (SAP) has also increased. In this study, data on pancreatitis were obtained from 2 states before and after cannabis legalization and compared with 2 states without legalized cannabis.

METHODS

Data were extracted from State Inpatient Databases from the states of Colorado and Washington before recreational cannabis legalization (2011) and after legalization (2015). Arizona and Florida were used as the nonlegalized cannabis states. Multivariable logistic regression models were fit for AP and SAP to determine a trend difference between legalized and nonlegalized cannabis states.

RESULTS

Cannabis use, AP, and SAP increased in all states. The increase in AP and SAP was not significantly different between the states that legalized cannabis use and those that did not. Legalized cannabis states had lower charges for AP and SAP and shorter length of hospitalizations.

CONCLUSIONS

The trend of AP and SAP increased during the study period, but this was not correlated to cannabis use. Cannabis users had lower hospitalization costs and hospital stay. The effects of other confounders such as cannabis dose and delivery methods, alcohol, tobacco, and others need to be studied further as use increases.

Cannabis in Gastroenterology: Watch Your Head! A Review of Use in Inflammatory Bowel Disease, Functional Gut Disorders, and Gut-Related Adverse Effects

Purpose of review

To review recent clinical evidence surrounding the use of cannabinoids and cannabis in gastrointestinal diseases, particularly inflammatory bowel disease (IBD) and functional gut disorders. A second aim is to evaluate the current status of gastrointestinal related adverse effects which have been linked to cannabis use, specifically cannabis hyperemesis syndrome (CHS) and acute pancreatitis.

Recent findings

Observational and prospective studies suggest that cannabinoids improve IBD symptoms. Small prospective clinical trials have not shown any effects on objective inflammatory findings, other than one recent paper in ulcerative colitis, in abstract form only, which suggests endoscopic improvement. Short duration mechanistic studies in functional gut disorders suggest cannabinoids may attenuate gastric emptying and slow colonic motility but appear to have less effect on sensory thresholds in the gut.

Summary

In general, while mostly uncontrolled data suggests cannabis may improve symptoms in IBD (and to a lesser degree functional gut disorders), this is not likely due to any substantial anti-inflammatory effect. Much remains unknown about CHS etiology and complete abstinence from cannabinoids remains the generally accepted treatment strategy. Population-based studies do not suggest that cannabis use is related to acute pancreatitis. Further research is certainly warranted.

The characteristics of acute necrotizing pancreatitis in different age stages: An MRI study

PURPOSE

To study the characteristics of acute necrotizing pancreatitis (ANP) in different age stages and their correlations with the clinical outcomes using magnetic resonance imaging (MRI).

METHOD

MRI of 716 patients with acute pancreatitis was retrospectively reviewed to assess the incidence and characteristics of ANP. On MRI, ANP was classified into three subtypes: extrapancreatic necrosis (EPN) alone, pancreatic necrosis (PN) alone and combined necrosis. The extent of necrosis was also quantified on MRI. All patients were divided into three age groups, that is, young,middle-aged and elderly groups, and these characteristics of ANP were compared among the three age groups. The endpoints of patients' clinical outcome were compared among different age groups and different characteristics of ANP.

RESULTS

Of the 716 patients, 129(18 %) were identified as ANP on MRI. The prevalence of ANP in the elderly group was the highest (28.9 %, p < 0.05). The patients in the middle-age and the elderly groups exhibited a higher risk of combined necrosis (56.9 %, 55.8 %; respectively), and elderly patients more frequently had extensive extrapancreatic involvement compared with young patients (65.9 % vs 21.4 %; p = 0.004); however, PN alone was more common in young patients. These characteristics of ANP were significantly bound up with clinical outcomes.

CONCLUSIONS

Different subtypes of ANP have different outcomes. More importantly, age needs to be considered as a factor of special concern in development of ANP.

The Impact of Cannabis Consumption on Mortality, Morbidity, and Cost in Acute Pancreatitis Patients in the United States: A 10-Year Analysis of the National Inpatient Sample

OBJECTIVES

The aim of this study was to identify the prevalence of cannabis use among all patients admitted with acute pancreatitis (AP) in the United States and to investigate the impact of cannabis use on AP mortality, morbidity, and cost of care.

METHODS

The National Inpatient Sample database from 2003 to 2013 was queried for all patients with AP and active exposure to cannabis. Outcomes included in-hospital mortality, length of stay, inflation adjusted charges, acute kidney injury, acute respiratory distress syndrome, and shock. Results were adjusted for age, sex, race, Charlson comorbidity index, median income quartile, and hospital characteristics.

RESULTS

More than 2.8 million patients with AP patients were analyzed. Cannabis-exposed (CE) patients' prevalence was 0.3%. Patients exposed to cannabis were younger and mostly males compared with non-cannabis-exposed patients. After adjusting for these factors, the CE group had significantly lower inpatient mortality compared with the noncannabis group (odds ratio, 0.17; 95% confidence interval, 0.06-0.53). Cannabis-exposed patients also had decreased length of stay, inflation-adjusted charges, acute kidney injury, ileus, shock, acute respiratory distress syndrome, and parenteral nutrition requirement.

CONCLUSIONS

Cannabis-exposed hospitalized patients with AP had lower age-adjusted, mortality, morbidity, and hospitalization-cost than non-cannabis-exposed patients.

Is There an Effect of Cannabis Consumption on Acute Pancreatitis?

BACKGROUND AND AIM

Twenty-percentage of acute pancreatitis (AP) cases is labeled as idiopathic. Cannabis remains the most frequently used illicit drug in the world. The aim of this study was to identify the prevalence of cannabis use among all patients with a first episode of AP, particularly in those labeled as idiopathic etiology, and determine any effect on AP severity.

METHODS

Retrospective cohort of all consecutive patients admitted with a first episode of AP at a large tertiary referral hospital from 01/2013 through 12/2014. AP was identified by ICD9 code, or lipase ≥ 3 times the upper limit of normal and abdominal pain consistent with AP. Cannabis users (CU) were identified via history or urine toxicology.

RESULTS

Four hundred and sixty patients were included. 54% were men, with a mean age of 48 years (range 17-89 years). Forty-eight patients (10%) were identified as CU. After adjusting for admission SIRS, age, and gender, cannabis use was not found to be an independent risk factor for persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU admission, length of stay, in-hospital infections, nor recurrent AP. Of note, AKI was least common among non-CU compared to CU (OR 0.4; p = 0.02; CI 0.2-0.9) and non-CU had a higher admission BISAP score (≥ 2) compared to CU (OR 2.5; p = 0.009; CI 1.2-4.9).

CONCLUSION

This is the largest study to date examining cannabis use in AP. Cannabis use was found across almost all etiologies of AP with a prevalence of 10% (48 cases), and in 9% (9 cases) of so-called idiopathic AP cases in this cohort, which could account as an association for approximately 2% of all AP cases. Cannabis use did not independently impact AP severity or mortality.

Cannabinoid Disposition After Human Intraperitoneal Use: AnInsight Into Intraperitoneal Pharmacokinetic Properties in Metastatic Cancer

BACKGROUND

Medicinal cannabis is prescribed under the provision of a controlled drug in the Australian Poisons Standard. However, multiple laws must be navigated in order for patients to obtain access and imported products can be expensive. Dose-response information for both efficacy and toxicity pertaining to medicinal cannabis is lacking. The pharmacokinetic properties of cannabis administered by traditional routes has been described but to date, there is no literature on the pharmacokinetic properties of an intraperitoneal cannabinoid emulsion.

CASE DESCRIPTION

A cachectic 56-year-old female with stage IV ovarian cancer and peritoneal metastases presented to hospital with fevers, abdominal distension and severe pain, vomiting, anorexia, dehydration and confusion. The patient reported receiving an intraperitoneal injection, purported to contain 12g of mixed cannabinoid (administered by a deregistered medical practitioner) two days prior to presentation. Additionally, cannabis oil oral capsules were administered in the hours prior to hospital admission.

RESULTS

THC concentrations were consistent with the clinical state but not with the known pharmacokinetic properties of cannabis nor of intraperitoneal absorption. THC concentrations at the time of presentation were predicted to be ~60ng/mL. Evidence suggests that blood THC concentrations >5ng/mL are associated with substantial cognitive and psychomotor impairment. The predicted time for concentrations to drop <5ng/mL was 49days after administration.

DISCUSSION

The unusual pharmacokinetic properties of the case suggest that there is a large amount unknown about cannabis pharmacokinetic properties. The pharmacokinetic properties of a large amount of a lipid soluble compound given intraperitoneally gave insights into the absorption and distribution of cannabinoids, particularly in the setting of metastatic malignancy.

Cannabis-Induced Acute Pancreatitis: A Systematic Review

OBJECTIVES

Cannabis is the most frequently consumed illicit drug in the world, with higher prevalence under the age of 35 years. Cannabis was first reported as a possible cause of acute pancreatitis (AP) in 2004. The aim of this systematic review is to examine cannabis use as an etiology of AP.

METHODS

A search using PubMed/Medline, Embase, Scopus, and Cochrane was performed without language or year limitations to May 1, 2016. Search terms were "Cannabis" and "Acute Pancreatitis" with all permutations. The search yielded 239 results. Acute pancreatitis was defined by meeting 2 of 3 Revised Atlanta Classification criteria. Cannabis-induced AP was defined by preceding use of cannabis and exclusion of common causes of AP when reported. Sixteen papers met inclusion criteria dating from 2004 to 2016.

RESULTS

There were 26 cases of cannabis-induced AP (23/26 men; 24/26 under the age of 35 y). Acute pancreatitis correlated with increased cannabis use in 18 patients. Recurrent AP related temporally to cannabis use was reported in 15 of 26. There are 13 reports of no further AP episodes after cannabis cessation.

CONCLUSIONS

Cannabis is a possible risk factor for AP and recurrent AP, occurring primarily in young patients under the age of 35 years. Toxicology screens should be considered in all patients with idiopathic AP.

Acute pancreatitis caused by Mycoplasma pneumoniae: an unusual etiology

It is well known that the most important etiologies of acute pancreatitis are gallstones and alcohol consumption. Once these causes have been ruled out, especially in young adults, it is important to consider less frequent etiologic factors such as drugs, trauma, malformations, autoimmunity or systemic diseases. Other rare and less well studied causes of this pathology are infections, among which Mycoplasma pneumoniae has been reported to cause acute pancreatitis as an unusual extrapulmonary manifestation. Here, we report the case of a 21-year-old patient who had acute idiopathic pancreatitis associated with an upper respiratory tract infection. After an in-depth study, all other causes of pancreatitis were ruled out and Mycoplasma was established as the clinical etiology.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Cytosolic and Calcium-Independent Phospholipases A2 Activation and Prostaglandins E2 Are Associated with Escherichia coli-Induced Reduction of Insulin Secretion in INS-1E Cells

It is suspected that microbial infections take part in the pathogenesis of diabetes mellitus type 1 (T1DM). Glucose-induced insulin secretion is accompanied by the release of free arachidonic acid (AA) mainly by cytosolic- and calcium independent phospholipases A₂ (cPLA₂ and iPLA₂). Insulinoma cell line (INS-1E) was infected with E. coli isolated from the blood culture of a patient with sepsis. Invasion assay, Scanning Electron Microscopy and Transmission Electron Microscopy demonstrated the capacity of E. coli to enter cells, which was reduced by PLA₂ inhibitors. Glucose-induced insulin secretion was significantly increased after acute infection (8h) but significantly decreased after chronic infection (72h). PLA₂ activities, cPLA₂, iPLA₂, phospho-cPLA₂, and COX-2 expressions were increased after acute and, even more, after chronic E. coli infection. The silencing of the two isoforms of PLA₂s, with specific cPLA₂- or iPLA₂-siRNAs, reduced insulin secretion after acute infection and determined a rise in insulin release after chronic infection. Prostaglandins E₂ (PGE₂) production was significantly elevated in INS-1E after long-term E. coli infection and the restored insulin secretion in presence of L798106, a specific EP3 antagonist, and NS-398, a COX-2 inhibitor, and the reduction of insulin secretion in presence of sulprostone, a specific EP3 agonist, revealed their involvement in the effects triggered by bacterial infection. The results obtained demonstrated that cPLA₂ and iPLA₂ play a key role in insulin secretion process after E. coli infection. The high concentration of AA released is transformed into PGE₂, which could be responsible for the reduced insulin secretion.

Cannabis Hyperemesis Syndrome in the Emergency Department: How Can a Specialized Addiction Team Be Useful? A Pilot Study

BACKGROUND

Chronic cannabis users may experience cyclical episodes of nausea and vomiting and learned behavior of hot bathing. This clinical condition, known as cannabis hyperemesis syndrome, was first reported in 2004.

OBJECTIVE

Our aim was to promote early recognition of this syndrome in emergency departments (EDs) and to increase referral to addiction specialists.

METHODS

Cannabis abusers were admitted to the ED for vomiting or abdominal pain from June 1, 2014 to January 1, 2015 and diagnosed with cannabis hyperemesis syndrome by a specialized addiction team. Then, medical records were examined retrospectively.

RESULTS

Seven young adults were included. Their mean age was 24.7 years (range 17-39 years) and the majority were men (male-to-female ratio 1.2). Biological and toxicological blood samples were taken in all patients. Tetrahydrocannabinol blood level was measured in 4 patients, with a mean blood concentration of 11.6 ng/mL. Radiographic examination including abdominal computed tomography and brain imaging were negative, as was upper endoscopy. Five patients compulsively took hot baths in an attempt to decrease the symptoms. Treatment was symptomatic. Five patients have started follow-up with the specialized addiction team.

CONCLUSIONS

Cannabis hyperemesis syndrome is still under-diagnosed 10 years after it was first described. Physicians should be aware of this syndrome to avoid repeated hospitalizations or esophageal complications. Greater awareness should lead to prompt treatment and prevention of future recurrence through cannabis cessation. Addiction specialists, as well as medical toxicologists, are experts in the management of cannabis abusers and can help re-establish the role of medical care in this population in collaboration with emergency physicians.