Molecular basis for pancreatitis

Early selective enteral feeding in combination with active decompression of duodenum in treatment of moderate and severe acute pancreatitis - A proof-of-concept clinical study

BACKGROUND

Acute pancreatitis (AP) is a significant clinical challenge with rising global incidence and substantial mortality rates, necessitating effective treatment strategies. Current guidelines recommend pain and fluid management and early enteral feeding to mitigate complications, yet optimal feeding route remains debated.

METHODS

We conducted a prospective, randomized, controlled trial at nine centers from October 2020 to May 2023, enrolling 154 patients with moderate to severe AP. Patients were stratified into biliary and non-biliary categories and randomized 1:1 to receive either standard of care (SoC) or SoC plus PandiCath®, a novel catheter enabling selective enteral feeding and duodenal decompression. The primary clinical endpoint (PCE) was a composite of de novo multiple organ dysfunction syndrome (MODS), infectious complications, pancreatic and intestinal fistula formation, bleeding, abdominal compartment syndrome, obstructive jaundice, and AP-related mortality.

RESULTS

In the primary modified intention-to-treat analysis, PandiCath® significantly reduced the PCE compared to SoC alone (P = 0.032). The Relative Risk (RR = 0.469, 95 % CI 0.228-0.964) and Number Needed to Treat (NNT = 6.384, 95 % CI 3.349-68.167) indicated its substantial clinical benefit, primarily driven by reduced rates of de novo MODS and infectious complications. These findings were further supported by the evaluation of other populations, including the standard intention-to-treat analysis.

CONCLUSION

PandiCath®, facilitating targeted enteral feeding while isolating and decompressing the duodenum, demonstrates promise in improving outcomes for AP patients at risk of severe complications. Further studies are warranted to validate these findings and explore optimal timing and patient selection for this intervention.

A safe method for rapid therapeutic pancreatic cooling

Acute pancreatitis (AP) has no targeted therapy. Previously, pancreatic cooling to 31°C-33°C and 24°C-27°C, respectively, ameliorated mild and severe AP in rats. Here, Yucatan pigs (40-50Kg) whose abdominal size and anatomy are like humans underwent pancreatic cooling. This was via a gastric cooling balloon placed endoscopically with catheters exteriorized on the abdominal wall. Laparoscopically placed wireless transmitters monitored pancreas tail, head, and urinary bladder temperatures. Controls included un-perfused water filled balloons, and sedation-only groups. Tap water perfusion (375 mL/min) over 1-month was well tolerated without sedation. Perfusion with ≤19°C water achieved pancreatic temperatures ≤32°C and perfusion at ≤10°C achieved ≤26°C in <90 min in sedated supine pigs, which normalized an hour after balloon evacuation. Bladder temperatures, behavioral, biochemical, hematological, and histological parameters were similar between groups. Therefore, rapid transgastric pancreatic cooling can be achieved safely in large animals with relevant anatomy like humans, warranting future clinical studies.

Ehmt2 inactivation in pancreatic epithelial cells shapes the transcriptional landscape and inflammation response of the whole pancreas

Introduction: The Euchromatic Histone Methyl Transferase Protein 2 (EHMT2), also known as G9a, deposits transcriptionally repressive chromatin marks that play pivotal roles in the maturation and homeostasis of multiple organs. Recently, we have shown that Ehmt2 inactivation in the mouse pancreas alters growth and immune gene expression networks, antagonizing Kras-mediated pancreatic cancer initiation and promotion. Here, we elucidate the essential role of Ehmt2 in maintaining a transcriptional landscape that protects organs from inflammation. Methods: Comparative RNA-seq studies between normal postnatal and young adult pancreatic tissue from Ehmt2 conditional knockout animals (Ehmt2 fl/fl ) targeted to the exocrine pancreatic epithelial cells (Pdx1-Cre and P48 Cre/+ ), reveal alterations in gene expression networks in the whole organ related to injury-inflammation-repair, suggesting an increased predisposition to damage. Thus, we induced an inflammation repair response in the Ehmt2 fl/fl pancreas and used a data science-based approach to integrate RNA-seq-derived pathways and networks, deconvolution digital cytology, and spatial transcriptomics. We also analyzed the tissue response to damage at the morphological, biochemical, and molecular pathology levels. Results and discussion: The Ehmt2 fl/fl pancreas displays an enhanced injury-inflammation-repair response, offering insights into fundamental molecular and cellular mechanisms involved in this process. More importantly, these data show that conditional Ehmt2 inactivation in exocrine cells reprograms the local environment to recruit mesenchymal and immunological cells needed to mount an increased inflammatory response. Mechanistically, this response is an enhanced injury-inflammation-repair reaction with a small contribution of specific Ehmt2-regulated transcripts. Thus, this new knowledge extends the mechanisms underlying the role of the Ehmt2-mediated pathway in suppressing pancreatic cancer initiation and modulating inflammatory pancreatic diseases.

EHMT2 Inactivation in Pancreatic Epithelial Cells Shapes the Transcriptional Landscape and Inflammation Response of the Whole Pancreas

The Euchromatic Histone Methyl Transferase Protein 2 (EHMT2), also known as G9a, deposits transcriptionally repressive chromatin marks that play pivotal roles in the maturation and homeostasis of multiple organs. Recently, we have shown that EHMT2 inactivation alters growth and immune gene expression networks, antagonizing KRAS-mediated pancreatic cancer initiation and promotion. Here, we elucidate the essential role of EHMT2 in maintaining a transcriptional landscape that protects organs from inflammation. Comparative RNA-seq studies between normal postnatal and young adult pancreatic tissue from EHMT2 conditional knockout animals ( EHMT2 fl/fl ) targeted to the exocrine pancreatic epithelial cells ( Pdx1-Cre and P48 Cre/+ ), reveal alterations in gene expression networks in the whole organ related to injury-inflammation-repair, suggesting an increased predisposition to damage. Thus, we induced an inflammation repair response in the EHMT2 fl/fl pancreas and used a data science-based approach to integrate RNA-seq-derived pathways and networks, deconvolution digital cytology, and spatial transcriptomics. We also analyzed the tissue response to damage at the morphological, biochemical, and molecular pathology levels. The EHMT2 fl/fl pancreas displays an enhanced injury-inflammation-repair response, offering insights into fundamental molecular and cellular mechanisms involved in this process. More importantly, these data show that conditional EHMT2 inactivation in exocrine cells reprograms the local environment to recruit mesenchymal and immunological cells needed to mount an increased inflammatory response. Mechanistically, this response is an enhanced injury-inflammation-repair reaction with a small contribution of specific EHMT2-regulated transcripts. Thus, this new knowledge extends the mechanisms underlying the role of the EHMT2-mediated pathway in suppressing pancreatic cancer initiation and modulating inflammatory pancreatic diseases.

Early selective enteral feeding in treatment of acute pancreatitis: A case report

BACKGROUND

Early initiation of enteral feeding is recognized to play a crucial role in improving the outcomes of treatment of acute pancreatitis. However, the method of administration of enteral nutrition remains debatable. We present the experience of treating a patient with moderate-severe acute pancreatitis, at high risk of progressing to a severe or fatal condition, using a novel method of selective feeding with duodenal isolation.

CASE SUMMARY

A 27-year-old female patient presented to the emergency unit of the hospital with a typical manifestation of acute pancreatitis. Despite a conventional treatment, the patient's condition deteriorated by day 2 of hospitalization. Using an endoscopic approach, a novel catheter PandiCath® was placed to the duodenum of the patient, isolating its segment between the duodenal bulb and the ligament of Treitz. In the isolated area created, a negative pressure was applied, followed by introduction of early selective enteral feeding. The patient's condition subsequently improved in a rapid manner, and no complications often associated with moderate-to-severe acute pancreatitis developed.

CONCLUSION

Within 48 h of starting treatment with the novel method, it can prevent the development of multiple organ failure and, when combined with minimally invasive drainage methods, help prevent infection.

Acute Pancreatitis Following Percutaneous Mechanical Thrombectomy of Left Common Iliac Vein

While parental or oral anticoagulation remains a mainstay of therapy for thrombosis, in sporadic clinical situations, percutaneous mechanical thrombectomy is favored. Percutaneous mechanical thrombectomy is a well-tolerated subtype of catheter-directed intervention resulting in thrombus breakdown and removal. This procedure combines endovascular mechanical thrombectomy in combination with pharmacologic thrombolysis allowing for a significant reduction in procedure time. Similar to other catheter-based procedures, common complications include hemorrhage, dissection, pseudoaneurysm, and perforations. Acute pancreatitis, in contrast, is a rare complication of percutaneous mechanical thrombectomy with only limited cases reported and is hypothesized to occur secondary to release of heme byproducts. Here, we present a case of acute pancreatitis following outpatient percutaneous mechanical thrombectomy of the left common iliac vein that ultimately required hospitalization, intensive care unit (ICU) admission, and standard medical management for pancreatitis.

Emerging Therapies to Prevent Post-ERCP Pancreatitis

PURPOSE OF REVIEW

The aim of this review is to evaluate emerging, novel therapies for the prevention of post-ERCP pancreatitis.

RECENT FINDINGS

Rectal indomethacin reduces the risk of pancreatitis in low- and average-risk patients, who comprise the majority of patients undergoing ERCP. An 8-h protocol of aggressive lactated Ringer's reduces the risk of pancreatitis in average-risk patients. Sublingual nitrate may provide additional benefit to rectal NSAIDs in preventing PEP. A tacrolimus trough > 2.5 ng/mL was recently shown to be associated with a lower risk of PEP in liver transplant patients undergoing ERCP. Routine usage of rectal indomethacin in all patients undergoing ERCP reduces the risk of PEP. Pancreatic-duct stents reduce the risk of PEP in high-risk patients. There is emerging data that aggressive hydration with lactated Ringer's and nitrates may further reduce PEP. Tacrolimus is a promising potential agent to prevent PEP but needs further clinical study.

The Cystic Fibrosis Transmembrane Conductance Regulator 470 Met Allele Is Associated with an Increased Risk of Chronic Pancreatitis in Both Asian and Caucasian Populations: A Meta-Analysis

Background: The Met470Val polymorphism (1540A>G [rs213950]) within the cystic fibrosis transmembrane conductance regulator (CFTR) protein has been reported to be associated with chronic pancreatitis (CP). The results remain inconclusive, and therefore, we performed this meta-analysis to clarify the association between M470V and CP risk. Methodology/Results: We conducted a meta-analysis of 7 case-control studies, including a total of 1121 CP patients and 2209 controls from Asian and Caucasian populations. We calculated the odds ratio (OR) and 95% confidence intervals (95% CI). Met470Val was found to be significantly associated with an increased risk of CP under all the genetic models (M vs. V, OR = 1.260, 95% CI: 1.134-1.399; MV vs. VV, OR = 1.292, 95% CI: 1.091-1.530; MM vs. VV, OR = 1.579, 95% CI: 1.274-1.956; MV/MV vs. VV, OR = 1.366, 95% CI: 1.165-1.603; MM vs. MV/VV, OR = 1.346, 95% CI: 1.114-1.621). Met470Val was also found to be significantly associated with an increased risk of idiopathic CP (ICP) in allele contrast, codominant, and recessive models (M vs. V, OR = 1.298, 95% CI: 1.020-1.653; MV vs. VV, OR = 1.297, 95% CI: 1.074-1.566; MM vs. VV, OR = 1.473, 95% CI: 1.165-1.862; MM vs. MV/VV, OR = 1.254, 95% CI: 1.023-1.538). Conclusions: The CFTR 470 M allele is significantly associated with an increased risk of CP in both Asian and Caucasian populations. The CFTR 470 M allele is also significantly associated with risk of ICP.

SPINK1 Gene is Significantly Associated With Pancreatitis: A Comprehensive Meta-Analysis

OBJECTIVES

This research was applied to case-control studies of the association between pancreatitis and SPINK1 gene to assess the joint evidence for the association, the influence of individual studies, and evidence for publication bias.

METHODS

MEDLINE and Embase were searched to identify longitudinal studies evaluating pancreatitis and SPINK1. Odds ratios (ORs) and 95% confidence interval (CI) were pooled using random-effect models and calculated using Carlin method. Publication bias was assessed using Egger et al's approach (A famous statistic method by Egger et al). Sensitivity, heterogeneity, and trim and fill analyses were conducted.

RESULTS

Based on the results, we found that (1) the results support for the association between pancreatitis and SPINK1, when analyzed totally and by subdivision (total [OR, 7.771; 95% CI, 5.232-11.543; P < 0.000]; European [OR,6.400; 95% CI, 4.346-9.426; P < 0.000]; Asian [OR, 11.823; 95% CI, 4.612-30.310; P < 0.000]; American [OR, 3.777; 95% CI, 1.596-8.939; P = 0.002]; mixed: [OR, 13.566; 95% CI, 2.322-79.252, P = 0.004]); (2) no evidence indicates that this association is accounted for by any one study, and no evidence indicates any publication bias exists.

CONCLUSIONS

The results indicated that SPINK1 gene, particularly the N34S mutation, has a genetic association with the development of pancreatitis.

Hsp90 regulation affects the treatment of glucocorticoid for pancreatitis-induced lung injury

Glucocorticoids are commonly used for the treatment of pancreatitis and complicated acute lung injury and help to reduce the mortality rates of both. The effect of gene variants in heat shock protein 90 (Hsp90), a key chaperone molecule of the glucocorticoid receptor (GR), on the therapeutic effect of glucocorticoids is unclear. Our study aims to investigate the different susceptibility to glucocorticoid treatment in BALB/c and C57BL/6 mice carrying different Hsp90 genotypes in an animal model of pancreatitis-induced lung injury. Compared with BALB/c mice, C57BL/6 mice have lower mortality rates, decreased water content in their lungs, and a lower level of IL-1 beta in an animal model of acute pancreatitis. C57BL/6 mice show a greater therapeutic effect and increased GR binding activities with glucocorticoid responsive element compared to BALB/c mice after a 0.4 mg/kg dexamethasone (DEX) treatment. Treatment with a higher dose of DEX (4 mg/kg) significantly reduced mortality rates and increased GR-GRE binding activity in both strains of mice, and there was no significant difference between the two strains. DEX did not exert a protective role after geldanamycin, a specific inhibitor of Hsp90, was administered in both strains of mice. Our study revealed that Hsp90 gene variants are responsible for the greater therapeutic effect of DEX in C57BL/6 mice compared to BALB/c mice, which implies that combining DEX treatment with Hsp90 regulation would promote the efficiency of DEX and would be an effective way to alleviate the side effects of hormone therapy.

Differential role of Hedgehog signaling in human pancreatic (patho-) physiology: An up to date review

Since the discovery of the Hedgehog (Hh) pathway in drosophila melanogaster, our knowledge of the role of Hh in embryonic development, inflammation, and cancerogenesis in humans has dramatically increased over the last decades. This is the case especially concerning the pancreas, however, real therapeutic breakthroughs are missing until now. In general, Hh signaling is essential for pancreatic organogenesis, development, and tissue maturation. In the case of acute pancreatitis, Hh has a protective role, whereas in chronic pancreatitis, Hh interacts with pancreatic stellate cells, leading to destructive parenchym fibrosis and atrophy, as well as to irregular tissue remodeling with potency of initiating cancerogenesis. In vitro and in situ analysis of Hh in pancreatic cancer revealed that the Hh pathway participates in the development of pancreatic precursor lesions and ductal adenocarcinoma including critical interactions with the tumor microenvironment. The application of specific inhibitors of components of the Hh pathway is currently subject of ongoing clinical trials (phases 1 and 2). Furthermore, a combination of Hh pathway inhibitors and established chemotherapeutic drugs could also represent a promising therapeutic approach. In this review, we give a structured survey of the role of the Hh pathway in pancreatic development, pancreatitis, pancreatic carcinogenesis and pancreatic cancer as well as an overview of current clinical trials concerning Hh pathway inhibitors and pancreas cancer.

Role of histone deacetylases in pancreas: Implications for pathogenesis and therapy

In the last years, our knowledge of the pathogenesis in acute and chronic pancreatitis (AP/CP) as well as in pancreatic cancerogenesis has significantly diversified. Nevertheless, the medicinal therapeutic options are still limited and therapeutic success and patient outcome are poor. Epigenetic deregulation of gene expression is known to contribute to development and progression of AP and CP as well as of pancreatic cancer. Therefore, the selective inhibition of aberrantly active epigenetic regulators can be an effective option for future therapies. Histone deacetylases (HDACs) are enzymes that remove an acetyl group from histone tails, thereby causing chromatin compaction and repression of transcription. In this review we present an overview of the currently available literature addressing the role of HDACs in the pancreas and in pancreatic diseases. In pancreatic cancerogenesis, HDACs play a role in the important process of epithelial-mesenchymal-transition, ubiquitin-proteasome pathway and, hypoxia-inducible-factor-1-angiogenesis. Finally, we focus on HDACs as potential therapeutic targets by summarizing currently available histone deacetylase inhibitors.

Novel lipophilic probe for detecting near-membrane reactive oxygen species responses and its application for studies of pancreatic acinar cells: effects of pyocyanin and L-ornithine

AIMS

The aim of this study was to develop a fluorescent reactive oxygen species (ROS) probe, which is preferentially localized in cellular membranes and displays a strong change in fluorescence upon oxidation. We also aimed to test the performance of this probe for detecting pathophysiologically relevant ROS responses in isolated cells.

RESULTS

We introduced a novel lipophilic ROS probe dihydrorhodamine B octadecyl ester (H2RB-C18). We then applied the new probe to characterize the ROS changes triggered by inducers of acute pancreatitis in pancreatic acinar cells. We resolved ROS changes produced by L-ornithine, L-arginine, cholecystokinin-8, acetylcholine, taurolithocholic acid 3-sulfate, palmitoleic acid ethyl ester, and the bacterial toxin pyocyanin. Particularly prominent ROS responses were induced by pyocyanin and L-ornithine. These ROS responses were accompanied by changes in cytosolic Ca(2+)concentration ([Ca(2+)]i), mitochondrial membrane potential (ΔΨ), and NAD(P)H concentration.

INNOVATION

The study describes a novel sensitive lipophilic ROS probe. The probe is particularly suitable for detecting ROS in near-membrane regions and therefore for reporting the ROS environment of plasma membrane channels and pumps.

CONCLUSIONS

In our experimental conditions, the novel probe was more sensitive than 5-(and-6)-chloromethyl-2',7'-dichlorodihydrofluorescein (CM-H2DCF) and dihydrorhodamine123 (H2R123) and allowed us to resolve ROS responses to secretagogues, pyocyanin, and L-ornithine. Changes in the fluorescence of the new probe were particularly prominent in the peripheral plasma membrane-associated regions. Our findings suggest that the new probe will be a useful tool in studies of the contribution of ROS to the pathophysiology of exocrine pancreas and other organs/tissues.

Antioxidative phytoceuticals to ameliorate pancreatitis in animal models: An answer from nature

Despite enthusiastic efforts directed at elucidating critical underlying mechanisms towards the identification of novel therapeutic targets for severe acute pancreatitis (SAP), the disease remains without a specific therapy to be executed within the first hours to days after onset of symptoms. Although earlier management for SAP should aim to either treat organ failure or reduce infectious complications, the current standard of care for the general management of AP in the first hours to days after onset of symptoms include intravenous fluid replacement, nutritional changes, and the use of analgesics with a close monitoring of vital signs. Furthermore, repeated evaluation of severity is very important, as the condition is particularly unstable in the early stages. In cases where biliary pancreatitis is accompanied by acute cholangitis or in cases where biliary stasis is suspected, an early endoscopic retrograde cholangiopancreatography is recommended. However, practice guidelines regarding the treatment of pancreatitis are suboptimal. In chronic pancreatitis, conservative management strategies include lifestyle modifications and dietary changes followed by analgesics and pancreatic enzyme supplementation. Recently, attention has been focused on phytoceuticals or antioxidants as agents that could surpass the limitations associated with currently available therapies. Because oxidative stress has been shown to play an important role in the pathogenesis of pancreatitis, antioxidants alone or combined with conventional therapy may improve oxidative-stress-induced organ damage. Interest in phytoceuticals stems from their potential use as simple, accurate tools for pancreatitis prognostication that could replace older and more tedious methods. Therefore, the use of antioxidative nutrition or phytoceuticals may represent a new direction for clinical research in pancreatitis. In this review article, recent advances in the understanding of the pathogenesis of pancreatitis are discussed and the paradigm shift underway to develop phytoceuticals and antioxidants to treat it is introduced. Despite the promise of studies evaluating the effects of antioxidants/phytoceuticals in pancreatitis, translation to the clinic has thus far been disappointing. However, it is expected that continued research will provide solid evidence to justify the use of antioxidative phytoceuticals in the treatment of pancreatitis.

A novel 2-step culture model for long-term in vitro maintenance of human pancreatic acinar cells

OBJECTIVES

Because of rapid loss of functional differentiation that regularly occurs in vitro, culture systems permitting long-term studies on pancreatic acinar cells pose a major technical challenge. We recently described a method for long-term cultivation of mouse acinar cells. Here, we introduce a novel 2-step culture system for human pancreatic acinar cells.

METHODS

The system involves 2 successive culture phases, which are as follows: primary organotypic culture of isolated acinar clusters under soft Matrigel (BD Biosciences, Bedford, Mass; range, 2-3 days) followed by dissociation and secondary monolayer culture of acinar cells (4 days). Basal and agonist-induced amylase secretion was used to assess the secretory capability.

RESULTS

Acinar clusters showed excellent morphology and stable basal amylase secretion throughout primary culture. Carbachol (0.1 mM/L) increased amylase secretion 1.4-fold (P = 0.021) versus basal in 3 independent 4-day secondary cultures. Despite the controversy about the presence and roles of cholecystokinin receptors in human acinar cells, one of them also responded to 0.1 and 10 nM/L concentrations of caerulein with 1.9- and 1.4-fold increases in the rate of amylase secretion, respectively.

CONCLUSIONS

Our technique allows cultured human acinar cells to maintain secretory differentiation for a minimum of 7 days. The technique provides novel prospects for in vitro modeling of the human exocrine pancreas.

Association of CTRC and SPINK1 gene variants with recurrent hospitalizations for pancreatitis or acute abdominal pain in lipoprotein lipase deficiency

Background: There are important inter-individual variations in the incidence and severity of acute pancreatitis in patients with severe hypertriglyceridemia. Several genes involved in triglyceride-rich lipoprotein metabolism or serine proteases pathways are known to influence the risk of pancreatitis.

Aim: To evaluate the association between genes regulating serine proteases, chymotrypsin C (CTRC) and serine peptidase inhibitor kazal type1 (SPINK1), and recurrence of hospitalizations for acute pancreatitis or severe abdominal pain in patients with Lipoprotein Lipase Deficiency (LPLD), a rare and extreme monogenic model of severe hypertriglyceridemia and pancreatitis.

Method: The CTRC and SPINK1 genes promoter and coding regions sequencing has been performed in a sample of 38 LPLD adults (22 men and 16 women) and 100 controls (53 men and 47 women). Estimation of the association of CTRC and SPINK1 gene variants or combinations of variants with history of hospitalizations for pancreatitis or acute abdominal pain in LPLD was investigated using non-parametric analyses with correction for multiple testing and logistic regression models controlling for age, gender, family history, and life habits.

Results: Gene sequencing followed by genotype-stratified analyses of the CTRC and SPINK1 genes in LPLD and controls revealed a positive association between recurrence of hospitalizations and the rs545634 (CTRC)—rs11319 (SPINK1) combination [OR = 41.4 (CI: 2.0–848.0); p = 0.016]. In all models, a positive family history of pancreatitis was a significant predictor of recurrent hospitalizations independently of the contribution of SPINK1 or CTRC (p < 0.001).

Conclusion: These results suggest that a positive family history of pancreatitis and genetic markers in the serine protease pathways could be associated with a risk of recurrent hospitalization for acute pancreatitis in severe hypertriglyceridemia due to LPLD.

Clinical efficacy of gabexate mesilate for acute pancreatitis in children

Children with acute pancreatitis have been treated by fasting and parenteral nutritional support, and to date, the efficacy of drugs for acute pancreatitis in children is unclear. Gabexate mesilate is a synthetic serine protease inhibitor used to prevent or treat acute pancreatitis in adult patients. The purpose of this study was to evaluate the clinical efficacy of gabexate for acute pancreatitis in children. Fifty-three children hospitalized with acute pancreatitis between 2004 and 2012 were divided between a gabexate-treated group (n = 26) and a control group without gabexate infusion (n = 27). The severity of acute pancreatitis was graded according to Balthazar scoring of computed tomography images. All subjects had a Balthazar score of <4 without pancreatic necrosis or organ failure. The median age of the patients was 11.8 years (range, 18 months-17 years). The durations of hospitalization, abdominal pain, and parenteral nutrition in the gabexate-treated group were significantly shorter than in control subjects (P = 0.032, P = 0.000, and P = 0.016, respectively). Serum levels of amylase and lipase were significantly lower in gabexate-infused children than in control subjects on day 7 (median amylase, 81 vs. 137 IU/L, P = 0.001; median lipase, 273 vs. 523 IU/L, P = 0.031).

CONCLUSION

The present study showed that gabexate infusion has some clinical benefits for acute pancreatitis in children. The clinical application of gabexate for managing acute pancreatitis in children may be appropriate beyond conventional therapy.

Inhibition of hydrogen sulfide synthesis provides protection for severe acute pancreatitis rats via apoptosis pathway

We aimed to investigate the relationship between the synthesis of hydrogen sulfide (H(2)S) and the pancreatic acinar cell apoptosis in severe acute pancreatitis (SAP) rats, as well as analyse the potential apoptotic pathway involved in this process. Sixty rats had been equally divided into four groups: sham, SAP, SAP + sodium hydrosulfide (NaHS) and SAP + DL-propargylglycine (PAG). 24 h after SAP induction, all surviving animals of each group were sacrificed to collect blood and tissue samples for the following measurements: the level of serum H(2)S as well as the levels of tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), H(2)S synthesizing activity, CSE mRNA and protein expression, maleic dialdehyde (MDA) and myeloperoxidase (MPO) activity, the expression of Bax, Bcl-2, caspase-3, -8 and -9, the release of cytochrome c and the activation of nuclear factor-kappa B (NF-κB), ERK1/2, JNK1/2 and p38 in pancreas. Furthermore, in situ detection of cell apoptosis was examined and the severity of pancreatic damage was analyzed by pathological grading and scoring. Results Significant differences in every index except IL-10 had been found between the SAP, NaHS and PAG groups (P < 0.05). Treatment with PAG obviously induced the pancreatic acinar cell apoptosis as well as improved all the pathological changes and inflammatory parameters. In contrast, administration of NaHS significantly attenuated apoptosis in the pancreas and aggravated the severity of pancreatic damage. Moreover, the expressions of caspase-3, -8, -9 and the release of cytochrome c were all increased in the apoptotic cells, and the activity of NF-κB as well as the phosphorylation of ERK1/2, JNK1/2 and p38 decreased accompanying with the reduction of the serum H(2)S level. H(2)S plays a pivotal role in the regulation of pancreatic acinar cell apoptosis in SAP rats. The present results showed that inhibition of H(2)S synthesis provided protection for SAP rats via inducing acinar cell apoptosis. This process acted through both extrinsic and intrinsic apoptotic pathways, and may be regulated by reducing the activity of NF-κB.

Sterile inflammation in the liver and pancreas

The ability of tissue injury to result in inflammation is a well-recognized phenomenon and is central to a number of common liver and pancreatic diseases including alcoholic steatohepatitis and pancreatitis, as well as drug-induced liver injury, non-alcoholic steatohepatitis, and pancreatitis from other causes. The requirements of extracellular damage-associated molecules and a cytosolic machinery labeled the inflammasome have been established in in vitro culture systems and in vivo disease models. This has provided a generic insight into the pathways involved, and the challenge now is to understand the specifics of these mechanisms in relation to the particular insults and organs involved. One reason for the excitement in this field is that a number of therapeutic candidates such a toll-like receptor antagonists and interleukin-1R antagonists are either approved or in clinical trials for other indications.

A comprehensive study indicates PRSS1 gene is significantly associated with pancreatitis

This comprehensive meta-analysis was applied to case-control studies of the association between pancreatitis and PRSS1 gene to assess the joint evidence for the association, the influence of individual studies, and evidence for publication bias. PubMed, EMBASE, and Cochrane Library were searched in order to identify longitudinal studies evaluating pancreatitis disease and PRSS1 gene. Odds ratios (ORs) were pooled using a random-effects model. For the case-control studies, the authors found 1) support for the association between total pancreatitis and PRSS1 gene, both totally analyzed and subdivided analyzed {total: [OR:10.799, 95%CI:(5.489-21.242), p<0.000]; Europe: [OR:9.795, 95%CI:(2.923-32.819), p<0.000]; Asia: [OR:11.994, 95%CI:(5.156-27.898), p<0.000]}. 2) no evidence showed that this association was accounted for by any one study, and 3) no evidence showed any publication bias exist. In conclusion, PRSS1 gene was significantly associated with total pancreatitis disease, both totally and separately.

Animal models for investigating chronic pancreatitis

Chronic pancreatitis is defined as a continuous or recurrent inflammatory disease of the pancreas characterized by progressive and irreversible morphological changes. It typically causes pain and permanent impairment of pancreatic function. In chronic pancreatitis areas of focal necrosis are followed by perilobular and intralobular fibrosis of the parenchyma, by stone formation in the pancreatic duct, calcifications in the parenchyma as well as the formation of pseudocysts. Late in the course of the disease a progressive loss of endocrine and exocrine function occurs. Despite advances in understanding the pathogenesis no causal treatment for chronic pancreatitis is presently available. Thus, there is a need for well characterized animal models for further investigations that allow translation to the human situation. This review summarizes existing experimental models and distinguishes them according to the type of pathological stimulus used for induction of pancreatitis. There is a special focus on pancreatic duct ligation, repetitive overstimulation with caerulein and chronic alcohol feeding. Secondly, attention is drawn to genetic models that have recently been generated and which mimic features of chronic pancreatitis in man. Each technique will be supplemented with data on the pathophysiological background of the model and their limitations will be discussed.

The causes and outcome of acute pancreatitis associated with serum lipase >10,000 u/l

OBJECTIVES

Our objective was to investigate the use of serum lipase levels >10,000 U/L as a tool for predicting the etiology of acute pancreatitis (AP) and to further address the relationship between lipase elevation and disease severity.

METHODS

We compared patients with AP and serum lipase >10,000 U/L (HL) with patients with AP and lower serum lipase levels (855-10,000 U/L). The etiology and severity of AP were recorded. Differences between groups were calculated.

RESULTS

Of the 114 patients in the HL group, the common etiologies of AP were biliary (68%), iatrogenic trauma (14%), and idiopathic (10%). Only one patient had alcoholic AP. Conversely, the common etiologies of AP in the 146-patient comparison group (lipase 855-10,000 U/L) were broader: biliary (34%), idiopathic (23%), alcohol (14%), and iatrogenic trauma (10%). Biliary AP was twice as common in the HL group (P < 0.0001) whereas alcoholic AP was significantly less common (P < 0.0001). The positive predictive value (PPV) for biliary AP of lipase >10,000 U/L was 80% whereas the negative predictive (NPV) for alcoholic AP was 99%. No difference between groups was observed in the severity markers including ICU admission, length of hospital stay, complications, or mortality.

CONCLUSIONS

In AP a serum lipase of >10,000 U/L at presentation is a useful marker and portends a biliary etiology while virtually excluding alcoholic AP. Therefore, if ultrasonography is negative for stones in this population, these data suggest workup with MRCP or EUS is warranted to evaluate for microlithiasis or sludge given the high likelihood of occult stone disease in these individuals.

A novel explant outgrowth culture model for mouse pancreatic acinar cells with long-term maintenance of secretory phenotype

The development of in vitro models able to support the long-term viability and function of acinar cells is critical for exploring pancreatic pathophysiology. Despite considerable efforts, no long-term culture models for non-transformed pancreatic acini exist. Our aim was to develop and validate culture conditions for this purpose. An explant outgrowth culture design was established in which mouse pancreatic explants were cultured at the gas-liquid interphase. An enriched culture medium, pH 7.8, was employed to promote the selective outgrowth of acinar cells and to support their differentiated phenotype. After 7 days, the outgrown primary acinar cells were subcultured and maintained up to an additional 7 days as secondary monolayers on tissue culture plastic. Measurements of basal and caerulein-induced amylase secretion, phase-contrast microscopy and immunohistochemical analyses were used to characterize the cultures. Explants retained their pancreatic cytoarchitecture for 2 days in vitro. A triphasic dose response to caerulein was detected in 7-day primary cultures. The maximal rate of secretion was 1.2-fold versus basal (p=0.009) and 1.7-fold versus 1 pM caerulein (p=0.014). In secondary cultures the response was biphasic with maximal rates of secretion being 1.9-fold in 3- to 4-day cultures at 0.01 nM (p=0.049) and 2-fold in 6- to 7-day cultures at 0.1 nM (p=0.003). The present culture model provides a means to obtain functionally competent normal mouse acinar cells for long-term in vitro experimentation.

Zymophagy, a novel selective autophagy pathway mediated by VMP1-USP9x-p62, prevents pancreatic cell death

Autophagy has recently elicited significant attention as a mechanism that either protects or promotes cell death, although different autophagy pathways, and the cellular context in which they occur, remain to be elucidated. We report a thorough cellular and biochemical characterization of a novel selective autophagy that works as a protective cell response. This new selective autophagy is activated in pancreatic acinar cells during pancreatitis-induced vesicular transport alteration to sequester and degrade potentially deleterious activated zymogen granules. We have coined the term "zymophagy" to refer to this process. The autophagy-related protein VMP1, the ubiquitin-protease USP9x, and the ubiquitin-binding protein p62 mediate zymophagy. Moreover, VMP1 interacts with USP9x, indicating that there is a close cooperation between the autophagy pathway and the ubiquitin recognition machinery required for selective autophagosome formation. Zymophagy is activated by experimental pancreatitis in genetically engineered mice and cultured pancreatic acinar cells and by acute pancreatitis in humans. Furthermore, zymophagy has pathophysiological relevance by controlling pancreatitis-induced intracellular zymogen activation and helping to prevent cell death. Together, these data reveal a novel selective form of autophagy mediated by the VMP1-USP9x-p62 pathway, as a cellular protective response.

Spinal toll like receptor 3 is involved in chronic pancreatitis-induced mechanical allodynia of rat

Background

Mechanisms underlying pain in chronic pancreatitis (CP) are incompletely understood. Our previous data showed that astrocytes were actively involved. However, it was unclear how astrocytic activation was induced in CP conditions. In the present study, we hypothesized that toll-like receptors (TLRs) were involved in astrocytic activation and pain behavior in CP-induced pain.

Results

To test our hypothesis, we first investigated the changes of TLR2-4 in the rat CP model induced by intrapancreatic infusion of trinitrobenzene sulfonic acid (TNBS). Western blot showed that after TNBS infusion, TLR3, but not TLR2 or TLR4, was increased gradually and maintained at a very high level for up to 5 w, which correlated with the changing course of mechanical allodynia. Double immunostaining suggested that TLR3 was highly expressed on astrocytes. Infusion with TLR3 antisense oligodeoxynucleotide (ASO) dose-dependently attenuated CP-induced allodynia. CP-induced astrocytic activation in the spinal cord was also significantly suppressed by TLR3 ASO. Furthermore, real-time PCR showed that IL-1β, TNF-α, IL-6 and monocyte chemotactic protein-1 (MCP-1) were significantly increased in spinal cord of pancreatic rats. In addition, TLR3 ASO significantly attenuated CP-induced up-regulation of IL-1β and MCP-1.

Conclusions

These results suggest a probable "TLR3-astrocytes-IL-1β/MCP-1" pathway as a positive feedback loop in the spinal dorsal horn in CP conditions. TLR3-mediated neuroimmune interactions could be new targets for treating persistent pain in CP patients.

Transcriptional regulation of CXC-ELR chemokines KC and MIP-2 in mouse pancreatic acini

Neutrophils and their chemoattractants, the CXC-ELR chemokines keratinocyte cytokine (KC) and macrophage inflammatory protein-2 (MIP-2), play a critical role in pancreatitis. While acute pancreatitis is initiated in acinar cells, it is unclear if these are a source of CXC-ELR chemokines. KC and MIP-2 have NF-κB, activator protein-1 (AP-1) sites in their promoter regions. However, previous studies have shown increased basal and reduced caerulein-induced AP-1 activation in harvested pancreatic tissue in vitro, which limits interpreting the caerulein-induced response. Moreover, recent studies suggest that NF-κB silencing in acinar cells alone may not be sufficient to reduce inflammation in acute pancreatitis. Thus the aim of this study was to determine whether acinar cells are a source of KC and MIP-2 and to understand their transcriptional regulation. Primary overnight-cultured murine pancreatic acini were used after confirming their ability to replicate physiological and pathological acinar cell responses. Upstream signaling resulting in KC, MIP-2 upregulation was studied along with activation of the transcription factors NF-κB and AP-1. Cultured acini replicated critical responses to physiological and pathological caerulein concentrations. KC and MIP-2 mRNA levels increased in response to supramaximal but not to physiological caerulein doses. This upregulation was calcium and protein kinase C (PKC), but not cAMP, dependent. NF-κB inhibition completely prevented upregulation of KC but not MIP-2. Complete suppression of MIP-2 upregulation required dual inhibition of NF-κB and AP-1. Acinar cells are a likely source of KC and MIP-2 upregulation during pancreatitis. This upregulation is dependent on calcium and PKC. MIP-2 upregulation requires both NF-κB and AP-1 in these cells. Thus dual inhibition of NF-κB and AP-1 may be a more successful strategy to reduce inflammation in pancreatitis than targeting NF-κB alone.

Laboratory models available to study alcohol-induced organ damage and immune variations: choosing the appropriate model

The morbidity and mortality resulting from alcohol-related diseases globally impose a substantive cost to society. To minimize the financial burden on society and improve the quality of life for individuals suffering from the ill effects of alcohol abuse, substantial research in the alcohol field is focused on understanding the mechanisms by which alcohol-related diseases develop and progress. Since ethical concerns and inherent difficulties limit the amount of alcohol abuse research that can be performed in humans, most studies are performed in laboratory animals. This article summarizes the various laboratory models of alcohol abuse that are currently available and are used to study the mechanisms by which alcohol abuse induces organ damage and immune defects. The strengths and weaknesses of each of the models are discussed. Integrated into the review are the presentations that were made in the symposium "Methods of Ethanol Application in Alcohol Model-How Long is Long Enough" at the joint 2008 Research Society on Alcoholism (RSA) and International Society for Biomedical Research on Alcoholism (ISBRA) meeting, Washington, DC, emphasizing the importance not only of selecting the most appropriate laboratory alcohol model to address the specific goals of a project but also of ensuring that the findings can be extrapolated to alcohol-induced diseases in humans.

Acute pancreatitis

BACKGROUND

Acute pancreatitis continues to be a serious illness, and the patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation.

AIMS

The present review is to highlight the classification, treatment and prognosis of acute pancreatitis. MATERIAL #ENTITYSTARTX00026;

METHODS

We reviewed the English-language literature (Medline) addressing pancreatitis.

RESULTS

Acute pancreatitis is frequently caused by gallstone disease or excess alcohol ingestion. There are a number of important issues regarding clinical highlights in the classification, treatment and prognosis of acute pancreatitis, and treatment options for complications of acute pancreatitis including pancreatic pseudocysts.

CONCLUSIONS

Multidisciplinary approach should be used for the management of the patient with acute pancreatitis.