Risk factors for chronic and recurrent pancreatitis after first attack of acute pancreatitis

Risk of and factors influencing the progression from acute to recurrent acute to chronic pancreatitis

OBJECTIVES & AIMS

Acute pancreatitis (AP) recurrence rates range from 11 to 36 % yet accurately predicting recurrent acute pancreatitis (RAP) and its progression to chronic pancreatitis (CP) after an initial episode remains challenging. Thus, this study explored the risk factors contributing to RAP and its progression to CP.

METHODS

This retrospective study included patients with AP from three tertiary medical centers between January 2010 and December 2017. The patients were followed up for up to 60 months. The primary endpoint was the incidence of RAP and CP; risk factors influencing these outcomes were also identified.

RESULTS

Overall, 501 patients were included, of which 164 (32.7 %) experienced RAP, and 71 (14.2 %) progressed to CP. The leading causes of AP were alcohol consumption (43.1 %), gallstones (41.5 %) and hypertriglyceridemia (4.4 %). Multivariate Cox regression analysis revealed that smoking (HR, 4.09; 95 % CI, 2.752-6.078, p < 0.001), and organ failure after 48 h of hospitalization (HR, 3.52; 95 % CI, 1.22-10.19, p < 0.02) were significant risk factors for RAP. Significant risk factors for progression to CP included age over 60 years (HR, 5.29; 95 % CI, 1.25-22.47, p = 0.024), smoking (HR, 2.50; 95 % CI, 1.04-6.01, p = 0.04), alcohol consumption (HR, 8.79; 95 % CI, 2.06-37.43, p = 0.003), computed tomography severity index (CTSI) (HR, 1.22; 95 % CI, 1.04-1.44, p = 0.015), and recurrence of AP (HR, 70.69; 95 % CI, 2.61-1914.86, p = 0.011). In alcohol-induced RAP patients, ≥3 recurrences (HR, 4.18; 95 % CI, 1.75-9.98, p = 0.001) was significant risk factor for progression to CP.

CONCLUSIONS

Alcohol consumption was the predominant cause of AP and RAP. The severity of the initial AP episode was the key determinant for RAP, and RAP was the most significant risk factor for the progression to CP. Therefore, smoking and alcohol cessation are important to prevent the development of recurrent AP and CP during long-term follow-up.

A Nomogram for Predicting the Transition From Recurrent Acute Pancreatitis to Chronic Pancreatitis

OBJECTIVES

Acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis are recognized as a continuum of pancreatic diseases. Recurrence increases the risk of progression to chronic pancreatitis. The aim of this study was to search for clinical features that may promote the progression of chronic pancreatitis in patients with recurrent acute pancreatitis.

MATERIALS AND METHODS

We retrospectively reviewed patients with recurrent acute pancreatitis from Medical Information Mart for Intensive Care-IV database. They were divided into a training cohort and a validation cohort. A nomogram was constructed based on clinical features during the second hospitalization. The discrimination and calibration of the nomogram were evaluated using the concordance index, area under the time-dependent receiver operating characteristic curve, and calibration plots.

RESULTS

A total of 432 recurrent acute pancreatitis patients were evaluated, of which 93 (21.53%) were diagnosed with chronic pancreatitis later. Age, biliary pancreatitis, admission interval, alcohol dependence, lipase, and platelet were selected. The concordance index was 0.717 (95% confidence interval: 0.691-0.743) for the training cohort and 0.718 (95% confidence interval: 0.662-0.774) for the validation cohort. The area under the time-dependent receiver operating characteristic curve was >0.7 over 1000 days.

CONCLUSIONS

A nomogram was developed and validated to evaluate the transition from recurrent acute pancreatitis to chronic pancreatitis.

Application of a Machine Learning Predictive Model for Recurrent Acute Pancreatitis

BACKGROUND AND AIM

Acute pancreatitis is the main cause of hospitalization for pancreatic disease. Some patients tend to have recurrent episodes after experiencing an episode of acute pancreatitis. This study aimed to construct predictive models for recurrent acute pancreatitis (RAP).

METHODS

A total of 531 patients who were hospitalized for the first episode of acute pancreatitis at the Affiliated Hospital of Southwest Medical University from January 2018 to December 2019 were enrolled in the study. We confirmed whether the patients had a second episode until December 31, 2021, through an electronic medical record system and telephone or WeChat follow-up. Clinical and follow-up data of patients were collected and randomly allocated to the training and test sets at a ratio of 7:3. The training set was used to select the best model, and the selected model was tested with the test set. The area under the receiver operating characteristic curves, sensitivity, specificity, positive predictive value, negative predictive value, accuracy, decision curve, and calibration plots were used to assess the efficacy of the models. Shapley additive explanation values were used to explain the model.

RESULTS

Considering multiple indices, XGBoost was the best model. The area under the receiver operating characteristic curves, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the XGBoost model in the test set were 0.779, 0.763, 0.883, 0.647, 0.341, and 0.922, respectively. According to the Shapley additive explanation values, drinking, smoking, higher levels of triglyceride, and the occurrence of ANC are associated with RAP.

CONCLUSION

The XGBoost model shows good performance in predicting RAP, which may help identify high-risk patients.

Heterozygous Spink1 c.194+2T>C mutation promotes chronic pancreatitis after acute attack in mice

BACKGROUND & AIMS

Mutations in genes, including serine protease inhibitor Kazal-type 1 (SPINK1), influence disease progression following sentinel acute pancreatitis event (SAPE) attacks. SPINK1 c.194+2T > C intron mutation is one of the main mutants of SPINK1，which leads to the impairment of SPINK1 function by causing skipping of exon 3. Research on the pathogenesis of SAPE attacks would contribute to the understanding of the outcomes of acute pancreatitis. Therefore, the aim of the study was to clarify the role of SPINK1 c.194+2T > C mutation in the CP progression after an AP attack.

METHODS

SAPE attacks were induced in wildtype and SPINK mutant (Spink1 c.194+2T > C) mice by cerulein injection. The mice were sacrificed at 24 h, 14 d, 28 d, and 42 d post-SAPE. Data-independent acquisition (DIA) proteomic analysis was performed for the identification of differentially expressed protein in the pancreatic tissues. Functional analyses were performed using THP-1 and HPSCs.

RESULTS

Following SAPE attack, the Spink1 c.194+2T > C mutant mice exhibited a more severe acute pancreatitis phenotype within 24 h. In the chronic phase, the chronic pancreatitis phenotype was more severe in the Spink1 c.194+2T > C mutant mice after SAPE. Proteomic analysis revealed elevated IL-33 level in Spink1 c.194+2T > C mutant mice. Further in vitro analyses revealed that IL-33 induced M2 polarization of macrophages and activation of pancreatic stellate cells.

CONCLUSION

Spink1 c.194+2T > C mutation plays an important role in the prognosis of patients following SAPE. Heterozygous Spink1 c.194+2T > C mutation promotes the development of chronic pancreatitis after an acute attack in mice through elevated IL-33 level and the induction of M2 polarization in coordination with pancreatic stellate cell activation.

Incidence of recurrent and chronic pancreatitis after acute pancreatitis: a systematic review and meta-analysis

Background

Acute pancreatitis (AP) has a high incidence, and patients can develop recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) after AP.

Objectives

We aimed to estimate the pooled incidence rates (IRs), cumulative incidences, and proportions of RAP and CP after AP.

Design

A systematic review and meta-analysis of studies reporting the proportion of RAP and CP after AP.

Data sources and methods

The systematic search was conducted in three (PubMed, EMBASE, and CENTRAL) databases on 19 December 2023. Articles reporting the proportion of RAP or CP in patients after the first and multiple episodes of AP were eligible. The random effects model was used to calculate the pooled IR with 95% confidence intervals (CIs). The I 2 value assessed heterogeneity. The risk of bias assessment was conducted with the Joanna Briggs Institute Critical Appraisal Tool.

Results

We included 119 articles in the quantitative synthesis and 29 in the IRs calculations. Our results showed that the IR of RAP in adult patients after AP was 5.26 per 100 person-years (CI: 3.99-6.94; I 2 = 93%), while in children, it was 4.64 per 100 person-years (CI: 2.73-7.87; I 2 = 88%). We also found that the IR of CP after AP was 1.4 per 100 person-years (CI: 0.9-2; I 2 = 75%), while after RAP, it increased to 4.3 per 100 person-years (CI: 3.1-6.0; I 2 = 76%). The risk of bias was moderate in the majority of the included studies.

Conclusion

Our results showed that RAP affects many patients with AP. Compared to patients with the first AP episode, RAP leads to a threefold higher IR for developing CP.

Trial registration

Our protocol was registered on PROSPERO (CRD42021283252).

Development of pancreatic diseases during long-term follow-up after acute pancreatitis: a post-hoc analysis of a prospective multicenter cohort

BACKGROUND AND AIM

More insight into the incidence of and factors associated with progression following a first episode of acute pancreatitis (AP) would offer opportunities for improvements in disease management and patient counseling.

METHODS

A long-term post hoc analysis of a prospective cohort of patients with AP (2008-2015) was performed. Primary endpoints were recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), and pancreatic cancer. Cumulative incidence calculations and risk analyses were performed.

RESULTS

Overall, 1184 patients with a median follow-up of 9 years (IQR: 7-11) were included. RAP and CP occurred in 301 patients (25%) and 72 patients (6%), with the highest incidences observed for alcoholic pancreatitis (40% and 22%). Pancreatic cancer was diagnosed in 14 patients (1%). Predictive factors for RAP were alcoholic and idiopathic pancreatitis (OR 2.70, 95% CI 1.51-4.82 and OR 2.06, 95% CI 1.40-3.02), and no pancreatic interventions (OR 1.82, 95% CI 1.10-3.01). Non-biliary etiology (alcohol: OR 5.24, 95% CI 1.94-14.16, idiopathic: OR 4.57, 95% CI 2.05-10.16, and other: OR 2.97, 95% CI 1.11-7.94), RAP (OR 4.93, 95% CI 2.84-8.58), prior pancreatic interventions (OR 3.10, 95% CI 1.20-8.02), smoking (OR 2.33, 95% CI 1.14-4.78), and male sex (OR 2.06, 95% CI 1.05-4.05) were independently associated with CP.

CONCLUSION

Disease progression was observed in a quarter of pancreatitis patients. We identified several risk factors that may be helpful to devise personalized strategies with the intention to reduce the impact of disease progression in patients with AP.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study

BACKGROUND

Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available.

OBJECTIVE

We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors.

METHODS

RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses.

RESULTS

Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates.

CONCLUSION

The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

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.

Structured alcohol cessation support program versus current practice in acute alcoholic pancreatitis (PANDA): Study protocol for a multicentre cluster randomised controlled trial

BACKGROUND/OBJECTIVES

The most important risk factor for recurrent pancreatitis after an episode of acute alcoholic pancreatitis is continuation of alcohol use. Current guidelines do not recommend any specific treatment strategy regarding alcohol cessation. The PANDA trial investigates whether implementation of a structured alcohol cessation support program prevents pancreatitis recurrence after a first episode of acute alcoholic pancreatitis.

METHODS

PANDA is a nationwide cluster randomised superiority trial. Participating hospitals are randomised for the investigational management, consisting of a structured alcohol cessation support program, or current practice. Patients with a first episode of acute pancreatitis caused by harmful drinking (AUDIT score >7 and < 16 for men and >6 and < 14 for women) will be included. The primary endpoint is recurrence of acute pancreatitis. Secondary endpoints include cessation or reduction of alcohol use, other alcohol-related diseases, mortality, quality of life, quality-adjusted life years (QALYs) and costs. The follow-up period comprises one year after inclusion.

DISCUSSION

This is the first multicentre trial with a cluster randomised trial design to investigate whether a structured alcohol cessation support program reduces recurrent acute pancreatitis in patients after a first episode of acute alcoholic pancreatitis, as compared with current practice.

TRIAL REGISTRATION

Netherlands Trial Registry (NL8852). Prospectively registered.

CT Features of Recurrent Acute Pancreatitis: Early Phase Versus Late Phase

OBJECTIVES

The aim of this study was to investigate the computed tomography (CT) features of recurrent acute pancreatitis (RAP) in the early phase and late phase.

METHODS

Recurrent acute pancreatitis data were obtained over the past 5 years. Recurrent acute pancreatitis patients were divided into 2 groups according to the time from RAP onset to performing CT examination: the early phase (first week) and late phase (after the first week) based on the 2012 revised Atlanta classification (RAC). Evaluation and comparison of patients' demographic data, RAC, CT findings, CT severity index (CTSI) score, and extrapancreatic inflammation on CT (EPIC) score were conducted in the 2 groups.

RESULTS

Hypertriglyceridemia was the most common cause of RAP in 679 of 686 patients (positive CT rate: 98.98%). Among 679 CT-positive patients, interstitial edematous pancreatitis and necrotizing pancreatitis accounted for 61.71% (419/679) and 38.29% (260/679), respectively. The CTSI and EPIC scores were higher in the late phase than in the early phase (both P 's < 0.05). The proportion of moderately severe and severe RAP patients based on RAC was higher in the late phase than in the early phase ( P < 0.05). Early-stage EPIC score was more accurate than CTSI and Acute Physiology and Chronic Health Evaluation (APACHE) II scores in predicting clinically severe RAP (EPIC vs CTSI; EPIC vs APACHE II, both P 's < 0.05).

CONCLUSIONS

Recurrent acute pancreatitis is more severe in the late phase than in the early phase. The EPIC score is more indicative of clinically severe RAP than CTSI and APACHE II scores in the early phase of RAP.

The risk of recurrent pancreatitis after first episode of acute pancreatitis in relation to etiology and severity of disease: A systematic review, meta-analysis and meta-regression analysis

BACKGROUND AND AIM

The study aims to determine and quantify the stratified risk of recurrent pancreatitis (RP) after the first episode of acute pancreatitis in relation to etiology and severity of disease.

METHODS

A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies investigating the risk of RP after the first episode of acute pancreatitis. Proportion meta-analysis models using random effects were constructed to calculate the weighted summary risks of RP. Meta-regression was performed to evaluate the effect of different variables on the pooled outcomes.

RESULTS

Analysis of 57,815 patients from 42 studies showed that the risk of RP after first episode was 19.8% (95% confidence interval [CI] 17.5-22.1%). The risk of RP was 11.9% (10.2-13.5%) after gallstone pancreatitis, 28.7% (23.5-33.9%) after alcohol-induced pancreatitis, 30.3% (15.5-45.0%) after hyperlipidemia-induced pancreatitis, 38.1% (28.9-47.3%) after autoimmune pancreatitis, 15.1% (11.6-18.6%) after idiopathic pancreatitis, 22.0% (16.9-27.1%) after mild pancreatitis, 23.9% (12.9-34.8%) after moderate pancreatitis, 21.6% (14.6-28.7%) after severe pancreatitis, and 6.6% (4.1-9.2%) after cholecystectomy following gallstone pancreatitis. Meta-regression confirmed that the results were not affected by the year of study (P = 0.541), sample size (P = 0.064), length of follow-up (P = 0.348), and age of patients (P = 0.138) in the included studies.

CONCLUSIONS

The risk of RP after the first episode of acute pancreatitis seems to be affected by the etiology of pancreatitis but not the severity of disease. The risks seem to be higher in patients with autoimmune pancreatitis, hyperlipidemia-induced pancreatitis, and alcohol-induced pancreatitis and lower in patients with gallstone pancreatitis and idiopathic pancreatitis.

Recurrence rates and risk factors for recurrence after first episode of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

There are a certain number of acute pancreatitis (AP) patients who may suffer from multiple episodes and develop recurrent acute pancreatitis (RAP), but recurrence rates and associated risk factors for RAP vary significantly in the published literature.

METHODS

We searched PubMed, Web of Science, Scopus, and Embase databases to identify all publications reporting AP recurrence until October 20th, 2022. Meta-analysis and meta-regression were performed to calculate the pooled estimates using the random-effects model.

RESULTS

A total of 36 studies met the inclusion criteria and all were used in pooled analyses. The overall rate of recurrence after first-time AP was 21% (95% CI, 18%- 24%), and pooled rates in biliary, alcoholic, idiopathic, and hypertriglyceridemia etiology patients were 12%, 30%, 25%, and 30%, respectively. After managing underlying causes post-discharge, the recurrence rate decreased (14% versus 4% for biliary, 30% versus 6% for alcoholic, and 30% versus 22% for hypertriglyceridemia AP). An increased risk of recurrence was reported in patients with a smoking history (odds ratio [OR] = 1.99), alcoholic etiology (OR = 1.72), male sex (hazard ratio [HR] = 1.63), and local complications (HR = 3.40), while biliary etiology was associated with lower recurrence rates (OR = 0.38).

CONCLUSION

More than one-fifth of AP patients experienced recurrence after discharge, with the highest recurrence rate in alcoholic and hypertriglyceridemia etiologies, and managing underlying causes post-discharge was related to decreased incidence. In addition, smoking history, alcoholic etiology, male gender, and presence of local complications were independent risks for the recurrence.

Incidence and outcomes in patients with acute cholangitis: a population-based study

OBJECTIVE

The importance of early ERCP (endoscopic retrograde cholangiopancreatography) in patients with acute cholangitis (AC) is controversial. The aims were to compare outcomes in those who had early ERCP within 24 h from diagnosis and those who had ERCP undertaken later and examine the general prognosis of AC patients.

METHODS

A prospective endoscopic database was used to identify all patients who underwent ERCP 2010-2021 at Landspitali University Hospital, diagnosed with cholangitis (k83.0) or calculus of bile duct with cholangitis (k80.3) according to ICD-10 diagnostic codes. Tokyo guidelines were used to verify the diagnosis and severity. Sepsis was analyzed by the Sepsis-3 criteria.

RESULTS

A total of 240 patients met the inclusion criteria, 107 women (45%), median age 74 years, mostly due to gallstones (75%) and malignancy (19%), 61 (25%) underwent ERCP early. Overall 30-day mortality was 3.3% and was not significantly different between the early and late ERCP groups (4.9% vs 2.5% respectively). Patients who underwent early ERCP were more likely to have severe cholangitis according to the Tokyo guidelines criteria than those who underwent ERCP later (31% vs 18%, p = 0.047) but had a shorter median hospital stay (4 vs. 6 days, p = 0.006). Sepsis was more common among those who had ERCP early than those who had late ERCP (33% vs 19%, p = 0.033).

CONCLUSIONS

The results indicate that for patients with AC the timing of ERCP is an important factor influencing the hospital stay, with shorter hospital stay for patients receiveing ERCP within 24 h, despite more severe cholangitis at diagnosis.

Ischemic Pancreatitis Is an Important Cause of Acute Pancreatitis in the Intensive Care Unit

BACKGROUND

Ischemic pancreatitis (IP) has mainly been described in case reports. The aims of the study were to assess the frequency, clinical characteristics and outcomes in patients with IP among patients hospitalized in the intensive care unit (ICU) for acute pancreatitis (AP).

METHODS

All patients with first time AP between 2011 and 2018 in the ICU of Landspitali Hospital, Iceland were retrospectively included. IP as an etiology required a clinical setting of circulatory shock, arterial hypotension, hypovolemia and/or arterial hypoxemia [PaO 2 of 60 mm Hg (8.0 kPa), or less] before the diagnosis of AP without prior history of abdominal pain to this episode. Other causes of AP were ruled out. IP patients were compared with patients with AP of other etiologies, also hospitalized in the ICU.

RESULTS

Overall 67 patients with AP were identified (median age 60 y, 37% females), 31% idiopathic, 24% alcoholic, 22% IP, 15% biliary, and 8% other causes. Overall, 15 (22%) fulfilled the predetermined criteria for IP, 9 males (64%), median age 62 years (interquartile range: 46 to 65). IP was preceded mainly by systemic shock (73%). Other causes included dehydration, hypoxia, or vessel occlusion to the pancreas. Necrosis of the pancreas was rare with one patient requiring pancreatic necrosectomy. Inpatient mortality was higher among patients with IP than in other patients with AP (33% vs. 14%, P =0.12).

CONCLUSIONS

IP was found in a significant proportion of AP patients hospitalized in the ICU. The main causes of IP were systemic shock and hypoxia. IP was associated with ∼30% mortality.

Characteristics of 30-Day All-Cause Hospital Readmissions Among Patients with Acute Pancreatitis and Substance Use

BACKGROUND/OBJECTIVES

Previous studies on healthcare resource utilization and 30-day readmission risks among patients with acute pancreatitis (AP) have focused upon opioid and alcohol use. The data on other substance types are lacking. In this study we aim to estimate the 30-day readmission rates, predictors of readmission, impact of readmission on patient outcomes and resulting economic burden among patients with AP and substance use in the USA.

METHODS

This was a retrospective cohort study, based upon data from 2017 National Readmission Database of adult patients with AP and substance use (alcohol in combination, opioid, cannabis, cocaine, sedatives, other stimulants, other hallucinogens, other psychoactive, inhalant and miscellaneous). We estimated the 30-day readmission rates and predictors of 30-day readmission.

RESULTS

Among 25,795 eligible patients, most were male, belonged to the lower income quartile, resided in the urban facility and had a Charlson comorbidity score of 0 or 1. The use of a combination of substances was the most common in 17,265 (66.9%) patients followed by only opioids in 4691 (18.2%) patients and only marijuana in 3839 (14.9%) patients. A total of 14.6% patients were readmitted within 30 days after discharge for non-elective causes with the highest risk of readmission within the 1st week after discharge with 5.2% readmissions. Among top ten causes of readmission, most of the principal diagnosis were related to AP in 53.1%. Compared to index admission, readmitted patients had significantly higher rates of acute cardiac failure, shock, and higher in-hospital mortality rate. Overall, readmission attributed to an additional 17,801 days of hospitalization resulting in a total of $150 million in hospitalization charges and $36 million in hospitalization costs in 2017. On multivariate analysis, chronic pancreatitis, self-discharge against medical advice, treatment at the highest volume centers, higher Charlson comorbidity index, increasing length of stay and severe disease were associated with higher odds of readmission while female gender and private insurance were associated with lower odds.

CONCLUSION

Readmission was associated with higher morbidity and in-hospital mortality among patients with AP and substance use and resulted in a significant monetary burden on the US healthcare system. Several factors identified in this study may be useful for categorizing patients at higher risk of readmission warranting special attention during discharge planning.

Clinical Characteristics of Patients With Chronic Pancreatitis With or Without Prior Acute Pancreatitis Are Different

OBJECTIVE

The aim of the study is to clarify the clinical characteristics of patients with chronic pancreatitis (CP) who had no prior acute pancreatitis (AP) attack.

METHODS

We retrospectively analyzed patients with CP who were admitted to our center between January 2012 and January 2020.

RESULTS

A total of 274 patients were divided into the following 3 groups: group A: CP without prior AP (n = 103 [37.6%]), group B: CP preceded by a single episode of AP (n = 39 [14.23%]), and group C: CP preceded by recurrent AP (n = 132 [48.18%]). At the diagnosis, patients in group A had a higher incidence of pancreatic duct stones (41.7% vs 25.8%, P = 0.012), higher proportion of idiopathic CP (68.9% vs 48.5%, P = 0.001), and higher mean pancreatic volume change rate (37.61% vs 10.48%, P = 0.007) compared with Group C. Patients in group A underwent the most episodes of extracorporeal shockwave lithotripsy therapy among the 3 groups (P < 0.001).

CONCLUSIONS

Approximately 37.6% of patients had no prior AP attack before CP diagnosis. Patients with CP without prior AP had higher incidence of pancreatic duct stones and pancreas volume shrank faster.

Radiomics and Its Applications and Progress in Pancreatitis: A Current State of the Art Review

Radiomics involves high-throughput extraction and analysis of quantitative information from medical images. Since it was proposed in 2012, there are some publications on the application of radiomics for (1) predicting recurrent acute pancreatitis (RAP), clinical severity of acute pancreatitis (AP), and extrapancreatic necrosis in AP; (2) differentiating mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC), focal autoimmune pancreatitis (AIP) from PDAC, and functional abdominal pain (functional gastrointestinal diseases) from RAP and chronic pancreatitis (CP); and (3) identifying CP and normal pancreas, and CP risk factors and complications. In this review, we aim to systematically summarize the applications and progress of radiomics in pancreatitis and it associated situations, so as to provide reference for related research.

Risk Factors for Recurrent Pancreatitis After First Episode of Acute Pancreatitis

Background

Methods

Results

Conclusion

current acute pancreatitis prevention by the elimination of alcohol and cigaette smoking (REAPPEAR): protocol of a randomised controlled trial and a cohort study

BACKGROUND/OBJECTIVES

Acute recurrent pancreatitis (ARP) due to alcohol and/or tobacco abuse is a preventable disease which lowers quality of life and can lead to chronic pancreatitis. The REAPPEAR study aims to investigate whether a combined patient education and cessation programme for smoking and alcohol prevents ARP.

METHODS AND ANALYSIS

The REAPPEAR study consists of an international multicentre randomised controlled trial (REAPPEAR-T) testing the efficacy of a cessation programme on alcohol and smoking and a prospective cohort study (REAPPEAR-C) assessing the effects of change in alcohol consumption and smoking (irrespective of intervention). Daily smoker patients hospitalised with alcohol-induced acute pancreatitis (AP) will be enrolled. All patients will receive a standard intervention priorly to encourage alcohol and smoking cessation. Participants will be subjected to laboratory testing, measurement of blood pressure and body mass index and will provide blood, hair and urine samples for later biomarker analysis. Addiction, motivation to change, socioeconomic status and quality of life will be evaluated with questionnaires. In the trial, patients will be randomised either to the cessation programme with 3-monthly visits or to the control group with annual visits. Participants of the cessation programme will receive a brief intervention at every visit with direct feedback on their alcohol consumption based on laboratory results. The primary endpoint will be the composite of 2-year all-cause recurrence rate of AP and/or 2-year all-cause mortality. The cost-effectiveness of the cessation programme will be evaluated. An estimated 182 participants will be enrolled per group to the REAPPEAR-T with further enrolment to the cohort.

ETHICS AND DISSEMINATION

The study was approved by the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (40394-10/2020/EÜIG), all local ethical approvals are in place. Results will be disseminated at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04647097.

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.

MALAT1 shuttled by extracellular vesicles promotes M1 polarization of macrophages to induce acute pancreatitis via miR-181a-5p/HMGB1 axis

Acute pancreatitis (AP) is a serious condition carrying a mortality of 25-40%. Extracellular vesicles (EVs) have reported to exert potential functions in cell-to-cell communication in diseases such as pancreatitis. Thus, we aimed at investigating the mechanisms by which EV-encapsulated metastasis-associated lung adenocarcinoma transcript-1 (MALAT1) might mediate the M1 polarization of macrophages in AP. Expression patterns of MALAT1, microRNA-181a-5p (miR-181a-5p) and high-mobility group box 1 protein (HMGB1) in serum of AP patients were determined. EVs were isolated from serum and pancreatic cells. The binding affinity among miR-181a-5p, MALAT1 and HMGB1 was identified. AP cells were co-cultured with EVs from caerulein-treated MPC-83 cells to determine the levels of M1/2 polarization markers and TLR4, NF-κB and IKBa. Finally, AP mouse models were established to study the effects of EV-encapsulated MALAT1 on the M1 polarization of macrophages in AP in vivo. MALAT1 was transferred into MPC-83 cells via EVs, which promoted M1 polarization of macrophages in AP. MALAT1 competitively bound to miR-181a-5p, which targeted HMGB1. Moreover, MALAT1 activated the TLR4 signalling pathway by regulating HMGB1. EV-encapsulated MALAT1 competitively bound to miR-181a-5p to upregulate the levels of IL-6 and TNF-α by regulating HMGB1 via activation of the TLR4 signalling pathway, thereby inducing M1 polarization of macrophages in AP. In vivo experimental results also confirmed that MALAT1 shuttled by EVs promoted M1 polarization of macrophages in AP via the miR-181a-5p/HMGB1/TLR4 axis. Overall, EV-loaded MALAT1 facilitated M1 polarization of macrophages in AP via miR-181a-5p/HMGB1/TLR4, highlighting a potential target for treating AP.

Individualized Prediction of Acute Pancreatitis Recurrence Using a Nomogram

OBJECTIVES

The objective of this study was to develop and validate a model, based on the blood biochemical (BBC) indexes, to predict the recurrence of acute pancreatitis patients.

METHODS

We retrospectively enrolled 923 acute pancreatitis patients (586 in the primary cohort and 337 in the validation cohort) from January 2014 to December 2016. Aiming for an extreme imbalance between recurrent acute pancreatitis (RAP) and non-RAP patients (about 1:4), we designed BBC index selection using least absolute shrinkage and selection operator regression, along with an ensemble-learning strategy to obtain a BBC signature. Multivariable logistic regression was used to build the RAP predictive model.

RESULTS

The BBC signature, consisting of 35 selected BBC indexes, was significantly higher in patients with RAP (P < 0.001). The area under the curve of the receiver operating characteristic curve of BBC signature model was 0.6534 in the primary cohort and 0.7173 in the validation cohort. The RAP predictive nomogram incorporating the BBC signature, age, hypertension, and diabetes showed better discrimination, with an area under the curve of 0.6538 in the primary cohort and 0.7212 in the validation cohort.

CONCLUSIONS

Our study developed a RAP predictive nomogram with good performance, which could be conveniently and efficiently used to optimize individualized prediction of RAP.

Identification of a Risk Profile for New-Onset Diabetes After Acute Pancreatitis

OBJECTIVES

There is a paucity of studies evaluating predictors of new-onset diabetes mellitus (DM) after acute pancreatitis (AP-related DM). We used a population-based database to evaluate predictors of AP-related DM.

METHODS

The Nationwide Readmissions Database (2010-2014) was used to identify all nondiabetic adults with an index primary diagnosis of AP. Multiple exclusions were applied to identify cohorts with and without AP-related DM. A case-control study was conducted to identify risk factors for developing AP-related DM within the calendar year.

RESULTS

We identified 2510 subjects with AP-related DM and 40,308 controls with AP who did not develop DM. Multivariable analysis revealed that increasing age (50-64 years; adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.14-1.60), male sex (aOR, 1.2; 95% CI, 1.03-1.40), lowest income quartile (aOR, 1.48; 95% CI, 1.18-1.84), Elixhauser comorbidity index of 3 or higher (aOR, 1.47; 95% CI, 1.23-1.75), components of metabolic syndrome (aOR, 2.12; 95% CI, 1.21-3.70), severe AP (aOR, 1.60; 95% CI, 1.34-1.90), and recurrent AP (aOR, 1.46; 95% CI, 1.24-1.72) were independently associated with increased risk of AP-related DM.

CONCLUSIONS

These population-level variables predictive of developing AP-related DM can potentially identify patients who may benefit from closer follow-up, intensive education, and implementation of preventative strategies.

Acute Pancreatitis: A Review

IMPORTANCE

In the United States, acute pancreatitis is one of the leading causes of hospital admission from gastrointestinal diseases, with approximately 300 000 emergency department visits each year. Outcomes from acute pancreatitis are influenced by risk stratification, fluid and nutritional management, and follow-up care and risk-reduction strategies, which are the subject of this review.

OBSERVATIONS

MEDLINE was searched via PubMed as was the Cochrane databases for English-language studies published between January 2009 and August 2020 for current recommendations for predictive scoring tools, fluid management and nutrition, and follow-up and risk-reduction strategies for acute pancreatitis. Several scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity (mild, moderately severe, and severe per the revised Atlanta classification) and mortality, but no one tool works well for all forms of acute pancreatitis. Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications, yet the optimal type and rate of fluid resuscitation have yet to be determined. The underlying etiology of acute pancreatitis should be sought in all patients, and risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis.

CONCLUSIONS AND RELEVANCE

Acute pancreatitis is a complex disease that varies in severity and course. Prompt diagnosis and stratification of severity influence proper management. Scoring systems are useful adjuncts but should not supersede clinical judgment. Fluid management and nutrition are very important aspects of care for acute pancreatitis.

[Inflammatory diseases of the pancreas: what new do we know about the mechanisms of their development in the 21st century?]

Inflammatory diseases of the pancreas can range from acute to acute recurrent and chronic pancreatitis. With the improvement of laboratory diagnostics in the 21st century, the mechanisms of the pro-inflammatory and anti-inflammatory role of tight junctions, in particular the transmembrane proteins occludin, claudine and JAMs, cytoplasmic Zo-proteins, and adherens junctions, in particular -catenin, -catenin, E-cadherin, selectins and ICAMs in the pathogenesis of acute and chronic pancreatitis have become more clear. The study of genetic factors in the development of acute and chronic pancreatitis showed the role of mutations in the genes SPINK1 N34S, PRSS1, CEL-HYB in the progression of the disease.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55-4.65 and 2.22-4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04-2.84 and 0.96-2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08-2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Progression to recurrent acute pancreatitis after a first attack of acute pancreatitis in adults

PURPOSE

Patients with a first attack of acute pancreatitis (AP) can develop recurrent acute pancreatitis (RAP). Hence, this study aimed to investigate the clinical features of the disease and the risk factors for RAP.

METHODS

We performed a retrospective study of 522 patients from Jan 1 to Dec 31, 2006. All patients with AP were followed for 36 months. The primary end point was the rate of RAP. The secondary end points were the risk factors that were evaluated by Cox regression analysis. The cumulative risk of RAP was assessed using Kaplan-Meier analysis.

RESULTS

56 of the 522 patients (10.7%) developed RAP. Among those RAP patients, 37 (7.1%) experienced one relapse, 10 (1.9%) experienced two relapses, and 9 (1.7%) experienced three or more relapses. Univariate analysis indicated that age (p = 0.016), male sex, etiology of AP (p = 0.001), local complications (p = 0.001) and Length of stay (LOS) (p = 0.007) were associated with RAP. Multivariate analysis with the Cox proportional hazards model showed that male sex (HR = 2.486, 95% CI, 0.169-0.960, p = 0.04), HTG-associated etiology (HR = 5.690, 95% CI, 2.138-15.146, p = 0.001), alcohol-associated etiology (HR = 5.867, 95% CI, 1.446-23.803, p = 0.013) and current local complications at index admission (HR = 8.917, 95% CI, 3.650-21.789, p = 0.001) were significant independent risk factors for RAP.

CONCLUSIONS

A first attack of AP led to RAP in 10.7% of patients within 3 years. Male sex was significantly associated with RAP. The etiologies of alcohol and HTG and local complications were the strongest risk factors for recurrent disease. Patients with these characteristics should be given special attention and followed-up closely.

A 5-Year Retrospective Cohort Study: Epidemiology, Etiology, Severity, and Outcomes of Acute Pancreatitis

OBJECTIVE

The aim of this study was to evaluate the epidemiology, etiology, severity, and outcomes of acute pancreatitis (AP) in the southern Sichuan region of China.

METHODS

All patients with first-attack AP between 2013 and 2018 in the Affiliated Hospital of Southwest Medical University were retrospectively identified. The etiology tendency was analyzed, and the relationship was defined with sex, aging, severity, length of stay, and mortality.

RESULTS

Three thousand twenty-eight patients were enrolled for analysis. Acute biliary pancreatitis had the highest incidence rate; the second and third most common causes were hypertriglyceridemic (14.4%) and alcoholic (14.2%), followed by idiopathic (13.6%), mixed etiology (12.9%), and miscellaneous (2.31%). Patients with alcoholic AP were more likely to be middle-aged males, whereas patients with acute biliary pancreatitis were more likely to be elderly females (P < 0.05). The overall mortality in the hospital was 1%, and there was no difference in each etiological groups (P > 0.05).

CONCLUSIONS

Biliary disease was the predominant etiology of AP in southern Sichuan of China, and hypertriglyceridemia ranked second. The proportion of hypertriglyceridemic AP and mixed etiology AP gradually increased, whereas idiopathic AP decreased. There were different etiology proportion of AP according age, sex, and severity.

Evaluation of Opioid Use in Acute Pancreatitis in Absence of Chronic Pancreatitis: Absence of Opioid Dependence an Important Feature

BACKGROUND

Chronic opioid use and dependence is common in patients with chronic pancreatitis. Patients with acute pancreatitis are frequently treated with opioids, but their risk for ongoing use is not well known. The aim of our study is to characterize opioid use in patients after an episode of acute pancreatitis and to assess persistent, chronic, and daily opioid use in such patients in the absence of chronic pancreatitis.

METHODS

This is a single-center review of prospectively enrolled patients with acute pancreatitis. Using the Massachusetts Prescription Awareness Tool, we recorded all opioid prescriptions (ie, frequency, duration, and amount) for patients from December 2016 to September 2019, after index hospitalization for acute pancreatitis. Patients with chronic pancreatitis were excluded. We used univariate and multivariate analysis to determine predictors of opioid use at discharge and subsequent follow-up over 18 months.

RESULTS

Of 235 enrolled patients who were opioid-naïve, 123 patients (52.3%) received opioids at discharge after index hospitalization. In follow-up over 18 months, 40 patients (17.0%) received additional opioid prescriptions. These patients had more severe disease, longer length of stay, and higher pain score at discharge. Patients with prior history of acute pancreatitis, local complications, and higher pain scores were twice as likely to subsequently be prescribed opioids. Persistent opioid use was seen only in recurrent acute pancreatitis. There was no daily or chronic opioid use.

CONCLUSIONS

In the absence of chronic pancreatitis, there was no daily or chronic use of opioids in patients with acute pancreatitis. Persistent use was only seen in patients with recurrent acute pancreatitis. These patients are at increased risk of chronic opioid use and dependence.

Clinical review of acute, recurrent, and chronic pancreatitis: Recent updates of 2013-2019 literature

The increasing prevalence of pancreatic disorders worldwide has provided challenges in its clinical care and management. This review was aimed to evaluate recent literature on diagnosis, treatment, and management of acute pancreatitis (AP), recurrent acute pancreatitis (RAP), as well as chronic pancreatitis (CP) documented during the past 5–6 years. An extensive literature review was carried out based on studies within the last 6 years (2013–2019). Articles were selected based on updates and therapeutic management. Critical appraisal of literature was performed using the Mixed Methods Appraisal Tool (MMAT), and a PRISMA flowchart was used to avoid bias. The study identified recent updates on the prophylactic treatment in preventing RAP. The risk factors and the therapeutic management options were evaluated and discussed. The findings show that although many lifesaving new protocols are available for implementation in clinical practice, current literature lacks detailed and comprehensive guidelines that cover special populations and comorbidities. The literature evaluated showed that eight genes were involved in pancreatitis, CASR, CFTR, CLDN2, CPA1, CTRC, PRSS1, SBDS, and SPINK1, but the most common gene implicated was found to be CFTR, at 11%. Therefore, it is recommended that a comprehensive guideline should be formulated to facilitate the diagnosis, management, treatment, and prophylactic measures of pancreatic disease. This could in turn reduce disease complications and hospitalization time, and improve clinical practice for management of pancreatitis.

The alterations of gut microbiota in mice with chronic pancreatitis

Background

The changes of intestinal microbiome are associated with inflammatory, metabolic, and malignant disorders, and there are no studies assessing the intestinal microbiota of mice with chronic pancreatitis (CP). Thus, we aim to investigate the variations in diversity, composition and function of intestinal microbiota in CP mice.

Methods

Sixteen male C57BL/6 mice were randomly selected, and divided into two groups, treated intraperitoneally with saline (normal control group, CT group) or ethanol + cerulein (experimental group, CP group) for 6 weeks. Body weight as measured in entire processes. Histopathological examination of CP index was conducted to verify the CP induction. Extracted DNA from colon samples was used for Illumina HiSeq sequencing of the bacterial V4 region of 16S rRNA gene and analyzed using Quantitative Insights Into Microbial Ecology (QIIME). Functional profiling of microbial communities was predicted with BugBase.

Results

Significant alterations of the gut microbiota were found in the CP mice compared to CT groups, as revealed by significant decrease in bacterial richness and diversity, declined the relative abundance of Lachnospiraceae_NK4A136, Ruminiclostridium and Roseburia, and increased the relative abundances of Bacteroides and Alloprevotella genera. Analysis of microbial community-level phenotypes revealed significant differences in nine phenotypes (aerobic, anaerobic, containing mobile elements, facultatively anaerobic, biofilm forming, gram-negative, gram-positive, potentially pathogenic, and stress tolerant) between CP group and CT group.

Conclusions

This study indicated that mice with CP had a distinct microbiota profile.