Medical treatment of acute pancreatitis

Acid suppression therapy, gastrointestinal bleeding and infection in acute pancreatitis - An international cohort study

BACKGROUND

Acid suppressing drugs (ASD) are generally used in acute pancreatitis (AP); however, large cohorts are not available to understand their efficiency and safety. Therefore, our aims were to evaluate the association between the administration of ASDs, the outcome of AP, the frequency of gastrointestinal (GI) bleeding and GI infection in patients with AP.

METHODS

We initiated an international survey and performed retrospective data analysis on AP patients hospitalized between January 2013 and December 2018.

RESULTS

Data of 17,422 adult patients with AP were collected from 59 centers of 23 countries. We found that 23.3% of patients received ASDs before and 86.6% during the course of AP. ASDs were prescribed to 57.6% of patients at discharge. ASD administration was associated with more severe AP and higher mortality. GI bleeding was reported in 4.7% of patients, and it was associated with pancreatitis severity, mortality and ASD therapy. Stool culture test was performed in 6.3% of the patients with 28.4% positive results. Clostridium difficile was the cause of GI infection in 60.5% of cases. Among the patients with GI infections, 28.9% received ASDs, whereas 24.1% were without any acid suppression treatment. GI infection was associated with more severe pancreatitis and higher mortality.

CONCLUSIONS

Although ASD therapy is widely used, it is unlikely to have beneficial effects either on the outcome of AP or on the prevention of GI bleeding during AP. Therefore, ASD therapy should be substantially decreased in the therapeutic management of AP.

Predictive factors for and incidence of hospital readmissions of patients with acute and chronic pancreatitis

BACKGROUND/OBJECTIVE

Acute and chronic pancreatitis are common gastroenterological disorders that have a fairly unpredictable long-term course often associated with unplanned hospital readmissions. Little is known about the factors that increase or decrease the risk for a hospital readmission. The aim of this study was to identify positive and negative predictive factors for hospital readmissions of patients with acute and chronic pancreatitis after in-hospital treatment.

METHODS

In a retrospective analysis data from the hospital information and reimbursement data system (HIS) were evaluated for 606 hospital stays for either acute or chronic pancreatitis between 2006 and 2011. Additional clinical data were obtained from a questionnaire covering quality of life and socio-economic status. A total of 973 patient variables were assessed by bivariate and multivariate analysis.

RESULTS

Between 2006 and 2011, 373 patients were admitted for acute or chronic pancreatitis; 107 patients of them were readmitted and 266 had only one hospitalization. Predictors for readmission were concomitant liver disease, presence of a pseudocyst or a suspected tumor of the pancreas as well as alcohol, tobacco or substance abuse or coexisting mental disorders. Patients who had undergone a CT-scan were more susceptible to readmission. Lower readmissions rates were found in patients with diabetes mellitus or gallstone disease as co-morbidity.

CONCLUSION

While factors like age and severity of the initial disease cannot be influenced to reduce the readmission rate for pancreatitis, variables like alcohol, tobacco and drug abuse can be addressed in outpatient programs to reduce disease recurrence and readmission rates for pancreatitis.

Endoscopic management of acute biliary pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Risk factors and nursing strategies for severe acute pancreatitis complicated with multiple organ dysfunction syndrome

AIM: To explore the risk factors and nursing strategies for severe acute pancreatitis (SAP) complicated with multiple organ dysfunction syndrome (MODS).

METHODS: Clinical data for 134 patients with SAP were retrospectively analyzed. Based on the presence of MODS or not, the patients were divided into two groups, those complicated with or without MODS. Risk factors and nursing strategies for SAP with MODS were then analyzed.

RESULTS: Logistic regression analysis demonstrated that shock, biliary obstruction, hyperlipidemia, hypoxemia, lung infection, pleural effusion, abdominal cavity room partition syndrome and Ranson's score, APACHE II score, and CT score were independent risk factors for SAP complicated with MODS (OR = 1.193, 1.016, 1.004, 1.193, 1.049, 1.055, 1.081, 1.100, 1.027, all P < 0.05). Nursing for SAP with MODS should focus on monitoring the patient's vital signs and strengthening the management of respiratory function, renal function, blood coagulation function and intestinal function.

CONCLUSION: Awareness of risk factors for SAP complicated with MODS should be raised to conduct active intervention to improve prognosis. Optimization of nursing management of SAP complicated with MODS can help reduce mortality.

Pancreatic nociception--revisiting the physiology and pathophysiology

BACKGROUND

Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas.

OBJECTIVES

This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC).

RESULTS

Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms.

CONCLUSIONS

Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.

[Ascending pancreatitis with mediastinal and parapharyngeal involvement]

A male patient who had suffered from alcohol dependence for several years was transferred to the Magdeburg University Hospital with signs of sepsis. The main cause for this was a previously unsuccessfully treated acute episode of chronic pancreatitis. Diagnostic imaging showed a distended ascending abscess extending above the larynx. During interdisciplinary emergency surgery, the neck, mediastinum and abdomen were drained and the pancreatic abscess removed. Under drainage, antibiotic therapy and parenteral nutrition the patient made a full recovery.

Evaluation of the effects of noniodinized and iodinized ionic contrast media and gadoteric acid in acute necrotizing pancreatitis: experimental study in rabbits

OBJECTIVE

To evaluate the effects of iodine contrast media and gadoteric acid in acute necrotizing pancreatitis.

METHODS

Fifty rabbits were distributed in 5 groups: 10 rabbits were assigned in the control group (group 5) and 40 rabbits were assigned in the pancreatitis group, wherein acute necrotizing pancreatitis was induced through retrograde injection of 5% sodium taurocholate (1 mL/kg weight) in the main pancreatic duct. After 3 hours, they were randomized to receive endovenous iodinized nonionic contrast medium (group 1), iodinized ionic contrast medium (group 2), gadoteric acid (group 3), and physiological serum at 0.9% (group 4). Six hours after induction of pancreatitis, these animals were reoperated. During surgery, pancreatic tissue flow through laser Doppler, hematometric values, biochemistry, and histopathology analysis by hematoxylin and eosin were done. Statistical analysis using Kruskal-Wallis, Fisher-Freeman-Halton, and parametric t tests was performed.

RESULTS

There was statistical significance when comparing tissue flow before and after induction of pancreatitis (P < 0.0001). Ionic and nonionic contrast media and gadoteric acid did not increase the grade of pancreatic necrosis (P > 0.05).

CONCLUSIONS

Ionic and nonionic contrast media and gadoteric acid did not produce adverse effects in the present model of acute necrotizing pancreatitis.

Computed tomography severity index and C-reactive protein values predicting mortality in emergency and intensive care units for patients with severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis is a multisystem disease in which various local and systemic complications lead to high mortality. We retrospectively examined the clinical and biochemical factors that may influence the risk of mortality on admission to emergency and intensive care units (ICUs).

METHODS

Sixty-eight patients were admitted into our hospital for acute pancreatitis and treated in our ICU for computed tomography-proven severe acute pancreatitis during the years 1997 to 2004. The clinical, biochemical, and radiologic data were reviewed from the computerized database, radiologic films, and patient records.

RESULTS

The mortality rate during the ICU stay was 18% (12/68) and that during the whole period of hospitalization 26% (18/68). A C-reactive protein (CRP) value over 150 was the only independent predictor of mortality on admission into the emergency unit, whereas the computed tomography severity index and the elevated CRP value over 150 predicted significantly and independently mortality on admission into the ICU. Linear backward regression analysis showed that high CRP values and respiratory failure on ICU admission correlate with longer ICU stay. Men's ICU stays were longer than those of women.

CONCLUSIONS

A high computed tomography severity index and CRP values over 150 on admission into the ICU are valuable predictors of the mortality risk. High CRP, renal and respiratory failure, and male gender are associated with longer ICU stay.

Acute pancreatitis-associated acute gastrointestinal mucosal lesions: incidence, characteristics, and clinical significance

GOALS AND BACKGROUND

Dyspeptic symptoms are associated with acute pancreatitis, but some of them may be related to acute gastrointestinal mucosal lesions (AGML) and need acid-suppressive therapy. The aim of this prospective study was to investigate the incidence, characteristics, and clinical significance of acute pancreatitis-associated AGML.

STUDY

From January to December 2005, a total of 197 patients with acute pancreatitis were included. All patients underwent computed tomography to evaluate the severity of acute pancreatitis. They also underwent upper gastrointestinal endoscopy to detect any AGML in upper gastrointestinal tract. The clinical and laboratory data from patients with or without AGML were compared.

RESULTS

Of the 197 patients, 128 patients (65%) were found having AGML by endoscopy. The locations of AGML included esophagus (9), stomach (50), duodenum (33), combined esophagus and stomach (10), and combined stomach and duodenum (26). The incidence of AGML was more frequent in patients with male gender (P<0.01). There was no statistical significance in relationship between AGML presence and age, etiologies of pancreatitis, severity of pancreatitis according to computed tomography grading or Ranson's score, serum total bilirubin level, duration of stay, or mortality. There was also no statistical significance in relationship between AGML location and etiologies of pancreatitis.

CONCLUSIONS

Sixty-five percent of patients with acute pancreatitis complicate with AGML and may benefit by acid-suppressive therapy. The occurrence of AGML is significantly increased in male patients and is not an early predictor of severity in acute pancreatitis.

Endoscopic management of acute pancreatitis

Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Managing nonmalignant chronic abdominal pain and malignant bowel obstruction

Evaluation of abdominal pain requires an understanding of the possible causes(benign or malignant) and recognition of typical patterns and clinical presentation. Abdominal pain has multiple causes; associated signs and symptoms may aid in the diagnosis. Remember that some patients will not have a textbook presentation, and unusual causes for pain must be considered. Those with chronic pancreatitis with structural complications should be operated on early, whereas those with other types of chronic pancreatitis should receive medical therapy focusing on alleviating symptoms. Control of the most troublesome symptoms will provide the best management for IBS. Pharmacologic success in bowel obstruction depends on the level and degree of obstruction. Decision making is based on reasonable expectations of survival, treatment-related success, performance status, and goals of care. Quality of life will be enhanced by appropriate symptom management.