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Wiley MB, Mehrotra K, Bauer J, Yazici C, Bialkowska AB, Jung B. Acute Pancreatitis: Current Clinical Approaches, Molecular Pathophysiology, and Potential Therapeutics. Pancreas 2023; 52:e335-e343. [PMID: 38127317 DOI: 10.1097/mpa.0000000000002259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Severe acute pancreatitis (SAP), pancreatic inflammation leading to multiorgan failure, is associated with high morbidity and mortality. There is a critical need to identify novel therapeutic strategies to improve clinical outcomes for SAP patients. MATERIALS AND METHODS A comprehensive literature review was performed to identify current clinical strategies, known molecular pathophysiology, and potential therapeutic targets for SAP. RESULTS Current clinical approaches focus on determining which patients will likely develop SAP. However, therapeutic options are limited to supportive care and fluid resuscitation. The application of a novel 5-cytokine panel accurately predicting disease outcomes in SAP suggests that molecular approaches will improve impact of future clinical trials in AP. CONCLUSIONS Inflammatory outcomes in acute pancreatitis are driven by several unique molecular signals, which compound to promote both local and systemic inflammation. The identification of master cytokine regulators is critical to developing therapeutics, which reduce inflammation through several mechanisms.
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Affiliation(s)
- Mark B Wiley
- From the Department of Medicine, University of Washington, Seattle, WA
| | - Kunaal Mehrotra
- From the Department of Medicine, University of Washington, Seattle, WA
| | - Jessica Bauer
- From the Department of Medicine, University of Washington, Seattle, WA
| | - Cemal Yazici
- Department of Medicine, University of Illinois Chicago, Chicago, IL
| | - Agnieszka B Bialkowska
- Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Barbara Jung
- From the Department of Medicine, University of Washington, Seattle, WA
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2
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Konarska-Bajda K, Ceranowicz P, Cieszkowski J, Ginter G, Stempniewicz A, Gałązka K, Kuśnierz-Cabala B, Dumnicka P, Bonior J, Warzecha Z. Administration of Warfarin Inhibits the Development of Cerulein-Induced Edematous Acute Pancreatitis in Rats. Biomolecules 2023; 13:948. [PMID: 37371528 DOI: 10.3390/biom13060948] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Acute pancreatitis (AP) is a severe disease with high morbidity and mortality in which inflammation and coagulation play crucial roles. The development of inflammation leads to vascular injury, endothelium and leukocytes stimulation, and an increased level of tissue factor, which results in the activation of the coagulation process. For this reason, anticoagulants may be considered as a therapeutic option in AP. Previous studies have shown that pretreatment with heparin, low-molecular-weight heparin (LMWH), or acenocoumarol inhibits the development of AP. The aim of the present study was to check if pretreatment with warfarin affects the development of edematous pancreatitis evoked by cerulein. Warfarin (90, 180, or 270 µg/kg/dose) or saline were administered intragastrically once a day for 7 days consecutively before the induction of AP. AP was evoked by the intraperitoneal administration of cerulein. The pre-administration of warfarin at doses of 90 or 180 µg/kg/dose reduced the histological signs of pancreatic damage in animals with the induction of AP. Additionally, other parameters of AP, such as an increase in the serum activity of lipase and amylase, the plasma concentration of D-dimer, and interleukin-1β, were decreased. In addition, pretreatment with warfarin administered at doses of 90 or 180 µg/kg/dose reversed the limitation of pancreatic blood flow evoked by AP development. Warfarin administered at a dose of 270 µg/kg/dose did not exhibit a preventive effect in cerulein-induced AP. Conclusion: Pretreatment with low doses of warfarin inhibits the development of AP evoked by the intraperitoneal administration of cerulein.
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Affiliation(s)
- Katarzyna Konarska-Bajda
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
- Department of Pediatric Cardiology, University Children's Hospital in Cracow, 30-663 Kraków, Poland
| | - Piotr Ceranowicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Jakub Cieszkowski
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Grzegorz Ginter
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Agnieszka Stempniewicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Krystyna Gałązka
- Department of Pathology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
| | - Beata Kuśnierz-Cabala
- Chair of Clinical Biochemistry/Chair of Medical Biochemistry, Jagiellonian University Medical College, 31-034 Kraków, Poland
| | - Paulina Dumnicka
- Chair of Clinical Biochemistry/Chair of Medical Biochemistry, Jagiellonian University Medical College, 31-034 Kraków, Poland
| | - Joanna Bonior
- Department of Medical Physiology, Faculty of Health Sciences, Jagiellonian University Medical College, 31-126 Kraków, Poland
| | - Zygmunt Warzecha
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Kraków, Poland
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3
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Verghis R, Blackwood B, McDowell C, Toner P, Hadfield D, Gordon AC, Clarke M, McAuley D. Heterogeneity of surrogate outcome measures used in critical care studies: A systematic review. Clin Trials 2023; 20:307-318. [PMID: 36946422 PMCID: PMC10617004 DOI: 10.1177/17407745231151842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The choice of outcome measure is a critical decision in the design of any clinical trial, but many Phase III clinical trials in critical care fail to detect a difference between the interventions being compared. This may be because the surrogate outcomes used to show beneficial effects in early phase trials (which informed the design of the subsequent Phase III trials) are not valid guides to the differences between the interventions for the main outcomes of the Phase III trials. We undertook a systematic review (1) to generate a list of outcome measures used in critical care trials, (2) to determine the variability in the outcome reporting in the respiratory subgroup and (3) to create a smaller list of potential early phase endpoints in the respiratory subgroup. METHODS Data related to outcomes were extracted from studies published in the six top-ranked critical care journals between 2010 and 2020. Outcomes were classified into subcategories and categories. A subset of early phase endpoints relevant to the respiratory subgroup was selected for further investigation. The variability of the outcomes and the variability in reporting was investigated. RESULTS A total of 6905 references were retrieved and a total of 294 separate outcomes were identified from 58 studies. The outcomes were then classified into 11 categories and 66 subcategories. A subset of 22 outcomes relevant for the respiratory group were identified as potential early phase outcomes. The summary statistics, time points and definitions show the outcomes are analysed and reported in different ways. CONCLUSION The outcome measures were defined, analysed and reported in a variety of ways. This creates difficulties for synthesising data in systematic reviews and planning definitive trials. This review once again highlights an urgent need for standardisation and validation of surrogate outcomes reported in critical care trials. Future work should aim to validate and develop a core outcome set for surrogate outcomes in critical care trials.
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Affiliation(s)
- Rejina Verghis
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | | | - Philip Toner
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel Hadfield
- Critical Care Unit, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Mike Clarke
- Centre of Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel McAuley
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
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4
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Jabaudon M, Genevrier A, Jaber S, Windisch O, Bulyez S, Laterre PF, Escudier E, Sossou A, Guerci P, Bertrand PM, Danin PE, Bonnassieux M, Bühler L, Heidegger CP, Chabanne R, Godet T, Roszyk L, Sapin V, Futier E, Pereira B, Constantin JM. Thoracic epidural analgesia in intensive care unit patients with acute pancreatitis: the EPIPAN multicenter randomized controlled trial. Crit Care 2023; 27:213. [PMID: 37259157 DOI: 10.1186/s13054-023-04502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Findings from preclinical studies and one pilot clinical trial suggest potential benefits of epidural analgesia in acute pancreatitis. We aimed to assess the efficacy of thoracic epidural analgesia, in addition to usual care, in improving clinical outcomes of intensive care unit patients with acute pancreatitis. METHODS A multicenter, open-label, randomized, controlled trial including adult patients with a clinical diagnosis of acute pancreatitis upon admission to the intensive care unit. Participants were randomly assigned (1:1) to a strategy combining thoracic epidural analgesia and usual care (intervention group) or a strategy of usual care alone (control group). The primary outcome was the number of ventilator-free days from randomization until day 30. RESULTS Between June 2014 and January 2019, 148 patients were enrolled, and 135 patients were included in the intention-to-treat analysis, with 65 patients randomly assigned to the intervention group and 70 to the control group. The number of ventilator-free days did not differ significantly between the intervention and control groups (median [interquartile range], 30 days [15-30] and 30 days [18-30], respectively; median absolute difference of - 0.0 days, 95% CI - 3.3 to 3.3; p = 0.59). Epidural analgesia was significantly associated with longer duration of invasive ventilation (median [interquartile range], 14 days [5-28] versus 6 days [2-13], p = 0.02). CONCLUSIONS In a population of intensive care unit adults with acute pancreatitis and low requirement for intubation, this first multicenter randomized trial did not show the hypothesized benefit of epidural analgesia in addition to usual care. Safety of epidural analgesia in this setting requires further investigation. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT02126332 , April 30, 2014.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Alexandra Genevrier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, CHU Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Olivier Windisch
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Bulyez
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- Service de Recherche Clinique en Soins Critiques, Pôle Anesthésie Douleur Urgences Réanimation, CHU Nîmes, Université de Montpellier, Nîmes, France
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Saint Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Etienne Escudier
- Department of Emergency Medicine and Intensive Care, Annecy Genevois General Hospital, Annecy, France
| | - Achille Sossou
- Department of Intensive Care Medicine, Emile-Roux General Hospital, Le Puy-en-Velay, France
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, CHU Nancy-Brabois, Nancy, France
- Institut Lorrain du Coeur Et Des Vaisseaux and INSERM U1116, Institut Lorrain du Coeur et des Vaisseaux, University of Lorraine, Nancy, France
| | | | - Pierre-Eric Danin
- Department of Intensive Care Medicine, CHU Nice, Nice, France
- INSERM U1065, Team 8, C3M, CHU de Nice, Nice, France
| | - Martin Bonnassieux
- Department of Intensive Care Medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Leo Bühler
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Claudia Paula Heidegger
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Russell Chabanne
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Laurence Roszyk
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Biochemistry and Molecular Genetics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, GRC 29, DMU DREAM, Pitié-Salpêtrière Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Paris, France
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5
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Eguchi T, Tsuji Y, Okada A, Inoue D, Tokumasu H, Iwane K, Nakai Y, Kusaka T, Uenoyama Y, Fujita K, Yokode M, Yamashita Y, Sawai Y, Asada M, Mikami T, Kawanami C, Kudo Y, Yazumi S, Sanuki T, Sakai A, Morita T, Sakuma Y, Uza N, Takada Y, Itani T, Kuriyama K, Matsumura K, Ikeda K, Someda H, Funatsu E, Katsushima S, Kodama Y, Seno H. Reducing the risk of developing walled-off necrosis in patients with acute necrotic collection using recombinant human soluble thrombomodulin. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:788-797. [PMID: 34174030 DOI: 10.1002/jhbp.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/20/2021] [Accepted: 06/12/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND/PURPOSE The purpose of the present study was to investigate the possibility of reducing clinical impacts of acute necrotic collection (ANC) on patients with acute pancreatitis (AP) using recombinant human soluble thrombomodulin (rTM). METHODS In this retrospective multicenter study, 233 consecutive AP patients with ANC and acute peripancreatic fluid collection (APFC) from 2012 to 2016 were enrolled. To assess clinical impacts of ANC, severity on admission (JPN score, JPN CT grade, and Modified CT severity index), development of walled-off necrosis (WON), imaging costs for follow-up, and mortality were recorded. Finally, we investigated whether rTM could reduce the clinical impacts, adjusting the severity using propensity analysis with Inverse probability of treatment weighting. RESULTS Patients with ANC developed WON with higher ratio than APFC (58/98 [59.2%] vs 20/135 [14.8%], OR = 8.3, P < .01]. Severity on admission and imaging costs for follow-up in ANC patients were significantly higher than those in APFC (P < .01). However, regarding mortality, there was no significant difference between patients with ANC and APFC (P = .41). Adjusting severity, it was revealed that rTM administration significantly reduced the risk of ANC developed WON (OR = 0.23, P = .01). CONCLUSIONS While ANC had a higher clinical impact than that of APFC, we found that early administration of rTM may reduce the impact.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Yoshihisa Tsuji
- Department of General Medicine, Sapporo Medical University, Sapporo, Japan.,Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan
| | - Hironobu Tokumasu
- Department of Clinical Research Institute, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Kosuke Iwane
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Gastroenterology and Hepatology, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan
| | - Yoshitaka Nakai
- Digestive disease Center, Department of Gastroenterology & Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Toshihiro Kusaka
- Digestive disease Center, Department of Gastroenterology & Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yoshito Uenoyama
- Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Koichi Fujita
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
| | - Masataka Yokode
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Gastroenterology and Hepatology, Kobe City Medical Center West Hospital, Kobe, Japan
| | - Yukimasa Yamashita
- Department of Gastroenterology and Hepatology, Kobe City Medical Center West Hospital, Kobe, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Takao Mikami
- Department of Gastroenterology and Hepatology, Otsu Red Cross Hospital, Shiga, Japan
| | - Chiharu Kawanami
- Department of Gastroenterology and Hepatology, Otsu Red Cross Hospital, Shiga, Japan
| | - Yasushi Kudo
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Shujiro Yazumi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Tsuyoshi Sanuki
- Department of Gastroenterology, Kita-harima Medical Center, Hyogo, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshihiro Morita
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yojiro Sakuma
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yutaka Takada
- Department of Gastroenterology, Nishi-Kobe Medical Center, Kobe, Japan
| | - Toshinao Itani
- Department of Gastroenterology, Nishi-Kobe Medical Center, Kobe, Japan
| | - Katsutoshi Kuriyama
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Shiga, Japan
| | - Kazuyoshi Matsumura
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Shiga, Japan
| | - Kazuki Ikeda
- Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan
| | - Hitoshi Someda
- Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan
| | - Eiji Funatsu
- Department of Gastroenterology and Hepatology, Chibune General Hospital, Osaka, Japan
| | - Shinji Katsushima
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuzo Kodama
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
PURPOSE OF REVIEW The present article will focus in pharmacologic agents that have been studied to improve acute pancreatitis outcomes, and to prevent the disease at different levels. RECENT FINDINGS Too little and too much early fluid resuscitation can be harmful. The optimal volume, rate, and duration of intravenous fluid therapy is still unknown. Nonopioid analgesics should be the first line of analgesia in patients with acute pancreatitis. A few pharmacologic agents evaluated in acute pancreatitis have resulted in positive pilot trials; however, larger randomized clinical trials (RCTs) are needed before final conclusions. Statin use is associated with lower incidence of acute pancreatitis in the general population and ongoing studies are evaluating its preventive role in acute pancreatitis recurrences. The preventive role of rectal indomethacin in post-endoscopic retrograde cholangiopancreatography pancreatitis is indisputable, with subject selection and timing of administration requiring further investigation. SUMMARY There is still no proven effective disease-specific pharmacologic therapy that changes the natural history of acute pancreatitis. New therapeutic targets and pharmacologic agents are in the horizon. Careful refinement in study design is needed when planning future RCTs. There is also a need for drug development aiming at reducing the incidence of the disease and preventing its sequelae.
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7
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Ahmed SU, Rana SS, Ahluwalia J, Varma N, Sharma R, Gupta R, Kang M. Role of thrombophilia in splanchnic venous thrombosis in acute pancreatitis. Ann Gastroenterol 2018; 31:371-378. [PMID: 29720864 PMCID: PMC5924861 DOI: 10.20524/aog.2018.0242] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/22/2018] [Indexed: 02/06/2023] Open
Abstract
Background: Splanchnic venous thrombosis (SVT) is a common vascular complication of acute pancreatitis (AP). We conducted this study to prospectively investigate the frequency, risk factors, and extent of SVT in patients with AP and to evaluate the role of thrombophilia in its causation. Methods: Patients with AP presenting between January 2015 and June 2016 were prospectively evaluated with contrast-enhanced computed tomography (CT) for the presence of SVT. These patients underwent a detailed analysis of coagulation parameters. Results: We evaluated 96 patients with AP (73 male, mean age 31.85±13.34 years), of whom 26 (27.1%) had SVT. Splenic vein, portal vein, and superior mesenteric vein involvement were seen in 22 (84.6%), 11 (42.3%), and 4 (15.3%) patients, respectively. Necrotizing pancreatitis, CT severity index (CTSI) >6 and modified CTSI >6 were significantly more frequent in patients with SVT than in those without (96.2% vs. 78.6%, 76.9% vs. 47.1%, and 92.3% vs. 67.1%, respectively). Proteins C and S, and antithrombin III deficiency were found in 23.8%, 33.3% and 31.0% of patients, respectively. Anti-β2-glycoprotein I and lupus anticoagulant were positive in 4.8% and 11.9% of patients, respectively. Factor V Leiden mutation analysis was positive in 6.1% of patients. Coagulation abnormality did not differ significantly between the patients with and without SVT. Conclusions: SVT is more common in patients with necrotizing pancreatitis, suggesting that local inflammation plays a major role in its causation. Thrombophilia is seen in one third of patients with AP but does not seem to increase the risk of SVT.
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Affiliation(s)
- Sobur Uddin Ahmed
- Department of Gastroenterology (Sobur Uddin Ahmed, Surinder S. Rana, Ravi Sharma), Chandigarh, India
| | - Surinder S Rana
- Department of Gastroenterology (Sobur Uddin Ahmed, Surinder S. Rana, Ravi Sharma), Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Hematology (Jasmina Ahluwalia, Neelam Varma), Chandigarh, India
| | - Neelam Varma
- Department of Hematology (Jasmina Ahluwalia, Neelam Varma), Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology (Sobur Uddin Ahmed, Surinder S. Rana, Ravi Sharma), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgery (Rajesh Gupta), Chandigarh, India
| | - Mandeep Kang
- Department of Radiology (Mandeep Kang), Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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8
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Fidan S, Erkut M, Cosar AM, Yogun Y, Örem A, Sönmez M, Arslan M. Higher Thrombin-Antithrombin III Complex Levels May Indicate Severe Acute Pancreatitis. Dig Dis 2018; 36:244-251. [PMID: 29332096 DOI: 10.1159/000485613] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/13/2017] [Indexed: 02/02/2023]
Abstract
AIM Coagulation disorders may develop in association with severe acute pancreatitis (AP). Plasma thrombin-antithrombin III complex (TAT) levels are one of the principal markers of coagulation disorder. The purpose of this study was to evaluate TAT and other hemostatic parameters in patients with AP and to examine whether or not these parameters indicate the severity of AP. METHOD Forty-six patients with AP (14 severe, 32 non-severe) and a 30-member healthy control group were recruited. The severity of AP was determined using the revised Atlanta classification. ELISA was used to measure patients' plasma TAT levels. RESULTS The TAT levels of AP patients at presentation were higher than those of the control group (p = 0.005). The plasma TAT levels of patients with severe AP were also significantly higher than those of patients with non-severe AP (p = 0.05) and of the control group (p < 0.001). The general accuracy, sensitivity and specificity of TAT levels in predicting the severity of AP were 77.4, 77.8, and 77.3% respectively. CONCLUSION The coagulation cascade was activated in the AP patients in our study, and this was shown to become more pronounced as severity of the disease increased. Plasma TAT levels at the time of presentation in patients with AP can be used as a marker for predicting the severity of the disease.
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Affiliation(s)
- Sami Fidan
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Murat Erkut
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Arif Mansur Cosar
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Yasar Yogun
- Department of Gastroenterology, Gebze Fatih State Hospital, Kocaeli, Turkey
| | - Asım Örem
- Department of Biochemistry, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Mehmet Sönmez
- Department of Hematology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Mehmet Arslan
- Department of Gastroenterology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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9
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Abstract
PURPOSE OF REVIEW The obesity pandemic poses a unique set of problems for acute pancreatitis - both by increasing acute pancreatitis incidence, and worsening acute pancreatitis severity. This review explores these associations, underlying mechanisms, and potential therapies. RECENT FINDINGS We review how the obesity associated increase in gallstones, surgical, and endoscopic interventions for obesity management, diabetes, and related medications such as incretin-based therapies and hypertriglyceridemia may increase the incidence of acute pancreatitis. The mechanism of how obesity may increase acute pancreatitis severity are discussed with a focus on cytokines, adipokines, damage-associated molecular patterns and unsaturated fatty acid-mediated lipotoxicity. The role of obesity in exacerbating pancreatic necrosis is discussed; focusing on obesity-associated pancreatic steatosis. We also discuss how peripancreatic fat necrosis worsens organ failure independent of pancreatic necrosis. Last, we discuss emerging therapies including choice of intravenous fluids and the use of lipase inhibitors which have shown promise during severe acute pancreatitis. SUMMARY We discuss how obesity may contribute to increasing acute pancreatitis incidence, the role of lipolytic unsaturated fatty acid release in worsening acute pancreatitis, and potential approaches, including appropriate fluid management and lipase inhibition in improving acute pancreatitis outcomes.
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Moggia E, Koti R, Belgaumkar AP, Fazio F, Pereira SP, Davidson BR, Gurusamy KS. Pharmacological interventions for acute pancreatitis. Cochrane Database Syst Rev 2017; 4:CD011384. [PMID: 28431202 PMCID: PMC6478067 DOI: 10.1002/14651858.cd011384.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND In people with acute pancreatitis, it is unclear what the role should be for medical treatment as an addition to supportive care such as fluid and electrolyte balance and organ support in people with organ failure. OBJECTIVES To assess the effects of different pharmacological interventions in people with acute pancreatitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 9), MEDLINE, Embase, Science Citation Index Expanded, and trial registers to October 2016 to identify randomised controlled trials (RCTs). We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered only RCTs performed in people with acute pancreatitis, irrespective of aetiology, severity, presence of infection, language, blinding, or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and extracted data. We did not perform a network meta-analysis as planned because of the lack of information on potential effect modifiers and differences of type of participants included in the different comparisons, when information was available. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) for the binary outcomes and rate ratios with 95% CIs for count outcomes using a fixed-effect model and random-effects model. MAIN RESULTS We included 84 RCTs with 8234 participants in this review. Six trials (N = 658) did not report any of the outcomes of interest for this review. The remaining 78 trials excluded 210 participants after randomisation. Thus, a total of 7366 participants in 78 trials contributed to one or more outcomes for this review. The treatments assessed in these 78 trials included antibiotics, antioxidants, aprotinin, atropine, calcitonin, cimetidine, EDTA (ethylenediaminetetraacetic acid), gabexate, glucagon, iniprol, lexipafant, NSAIDs (non-steroidal anti-inflammatory drugs), octreotide, oxyphenonium, probiotics, activated protein C, somatostatin, somatostatin plus omeprazole, somatostatin plus ulinastatin, thymosin, ulinastatin, and inactive control. Apart from the comparison of antibiotics versus control, which included a large proportion of participants with necrotising pancreatitis, the remaining comparisons had only a small proportion of patients with this condition. Most trials included either only participants with severe acute pancreatitis or included a mixture of participants with mild acute pancreatitis and severe acute pancreatitis (75 trials). Overall, the risk of bias in trials was unclear or high for all but one of the trials. SOURCE OF FUNDING seven trials were not funded or funded by agencies without vested interest in results. Pharmaceutical companies partially or fully funded 21 trials. The source of funding was not available from the remaining trials.Since we considered short-term mortality as the most important outcome, we presented only these results in detail in the abstract. Sixty-seven studies including 6638 participants reported short-term mortality. There was no evidence of any differences in short-term mortality in any of the comparisons (very low-quality evidence). With regards to other primary outcomes, serious adverse events (number) were lower than control in participants taking lexipafant (rate ratio 0.67, 95% CI 0.46 to 0.96; N = 290; 1 study; very low-quality evidence), octreotide (rate ratio 0.74, 95% CI 0.60 to 0.89; N = 770; 5 studies; very low-quality evidence), somatostatin plus omeprazole (rate ratio 0.36, 95% CI 0.19 to 0.70; N = 140; 1 study; low-quality evidence), and somatostatin plus ulinastatin (rate ratio 0.30, 95% CI 0.15 to 0.60; N = 122; 1 study; low-quality evidence). The proportion of people with organ failure was lower in octreotide than control (OR 0.51, 95% CI 0.27 to 0.97; N = 430; 3 studies; very low-quality evidence). The proportion of people with sepsis was lower in lexipafant than control (OR 0.26, 95% CI 0.08 to 0.83; N = 290; 1 study; very low-quality evidence). There was no evidence of differences in any of the remaining comparisons in these outcomes or for any of the remaining primary outcomes (the proportion of participants experiencing at least one serious adverse event and the occurrence of infected pancreatic necrosis). None of the trials reported heath-related quality of life. AUTHORS' CONCLUSIONS Very low-quality evidence suggests that none of the pharmacological treatments studied decrease short-term mortality in people with acute pancreatitis. However, the confidence intervals were wide and consistent with an increase or decrease in short-term mortality due to the interventions. We did not find consistent clinical benefits with any intervention. Because of the limitations in the prognostic scoring systems and because damage to organs may occur in acute pancreatitis before they are clinically manifest, future trials should consider including pancreatitis of all severity but power the study to measure the differences in the subgroup of people with severe acute pancreatitis. It may be difficult to power the studies based on mortality. Future trials in participants with acute pancreatitis should consider other outcomes such as complications or health-related quality of life as primary outcomes. Such trials should include health-related quality of life, costs, and return to work as outcomes and should follow patients for at least three months (preferably for at least one year).
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Affiliation(s)
- Elisabetta Moggia
- IRCCS Humanitas Research HospitalDepartment of General and Digestive SurgeryVia Manzoni 5620089 RozzanoMilanItaly20089
| | - Rahul Koti
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalPond StreetLondonUKNW3 2QG
| | - Ajay P Belgaumkar
- Ashford and St Peter's NHS TrustDept of Upper GI SurgerySt Peter's HospitalGuildford RoadChertseyUKKT16 0PZ
| | - Federico Fazio
- Royal Free Hospital, NHS Foundation TrustHPB and Liver Transplant SurgeryLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalPond StreetLondonUKNW3 2QG
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalPond StreetLondonUKNW3 2QG
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Dumnicka P, Maduzia D, Ceranowicz P, Olszanecki R, Drożdż R, Kuśnierz-Cabala B. The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications. Int J Mol Sci 2017; 18:E354. [PMID: 28208708 PMCID: PMC5343889 DOI: 10.3390/ijms18020354] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/17/2017] [Accepted: 01/31/2017] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease with varied severity, ranging from mild local inflammation to severe systemic involvement resulting in substantial mortality. Early pathologic events in AP, both local and systemic, are associated with vascular derangements, including endothelial activation and injury, dysregulation of vasomotor tone, increased vascular permeability, increased leukocyte migration to tissues, and activation of coagulation. The purpose of the review was to summarize current evidence regarding the interplay between inflammation, coagulation and endothelial dysfunction in the early phase of AP. Practical aspects were emphasized: (1) we summarized available data on diagnostic usefulness of the markers of endothelial dysfunction and activated coagulation in early prediction of severe AP; (2) we reviewed in detail the results of experimental studies and clinical trials targeting coagulation-inflammation interactions in severe AP. Among laboratory tests, d-dimer and angiopoietin-2 measurements seem the most useful in early prediction of severe AP. Although most clinical trials evaluating anticoagulants in treatment of severe AP did not show benefits, they also did not show significantly increased bleeding risk. Promising results of human trials were published for low molecular weight heparin treatment. Several anticoagulants that proved beneficial in animal experiments are thus worth testing in patients.
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Affiliation(s)
- Paulina Dumnicka
- Department of Medical Diagnostics, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland.
| | - Dawid Maduzia
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Kraków, Poland.
| | - Piotr Ceranowicz
- Department of Physiology, Jagiellonian University Medical College, Grzegórzecka 16, 31-531 Kraków, Poland.
| | - Rafał Olszanecki
- Department of Pharmacology, Jagiellonian University Medical College, Grzegórzecka 16, 31-531 Kraków, Poland.
| | - Ryszard Drożdż
- Department of Medical Diagnostics, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland.
| | - Beata Kuśnierz-Cabala
- Department of Diagnostics, Chair of Clinical Biochemistry, Jagiellonian University Medical College, Kopernika 15A, 31-501 Kraków, Poland.
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Meta-Analysis of Early Nutrition: The Benefits of Enteral Feeding Compared to a Nil Per Os Diet Not Only in Severe, but Also in Mild and Moderate Acute Pancreatitis. Int J Mol Sci 2016; 17:ijms17101691. [PMID: 27775609 PMCID: PMC5085723 DOI: 10.3390/ijms17101691] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/10/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022] Open
Abstract
The recently published guidelines for acute pancreatitis (AP) suggest that enteral nutrition (EN) should be the primary therapy in patients suffering from severe acute pancreatitis (SAP); however, none of the guidelines have recommendations on mild and moderate AP (MAP). A meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). The following PICO (problem, intervention, comparison, outcome) was applied: P: nutrition in AP; I: enteral nutrition (EN); C: nil per os diet (NPO); and O: outcome. There were 717 articles found in Embase, 831 in PubMed, and 10 in the Cochrane database. Altogether, seven SAP and six MAP articles were suitable for analyses. In SAP, forest plots were used to illustrate three primary endpoints (mortality, multiorgan failure, and intervention). In MAP, 14 additional secondary endpoints were analyzed (such as CRP (C-reactive protein), WCC (white cell count), complications, etc.). After pooling the data, the Mann-Whitney U test was used to detect significant differences. Funnel plots were created for testing heterogeneity. All of the primary endpoints investigated showed that EN is beneficial vs. NPO in SAP. In MAP, all of the six articles found merit in EN. Analyses of the primary endpoints did not show significant differences between the groups; however, analyzing the 17 endpoints together showed a significant difference in favor of EN vs. NPO. EN is beneficial compared to a nil per os diet not only in severe, but also in mild and moderate AP.
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13
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Yang N, Zhang DL, Hao JY. Coagulopathy and the prognostic potential of D-dimer in hyperlipidemia-induced acute pancreatitis. Hepatobiliary Pancreat Dis Int 2015; 14:633-41. [PMID: 26663012 DOI: 10.1016/s1499-3872(15)60376-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Coagulopathy and its association with disease severity in hyperlipidemia (HL)- and non-hyperlipidemia (NHL)-induced acute pancreatitis (AP) are not clear. The present study was to evaluate the relationship between coagulation homeostasis and AP. METHODS This study included 106 AP patients admitted to our hospital between October 2011 and January 2013. Stratified by disease severity, the patients were divided into two groups: a mild AP (MAP) group (n=69); and a moderately severe AP (MSAP) group (n=37). Based on disease etiology, there were 31 HL-induced AP (HLP) cases and 75 NHL-induced AP (NHLP) cases. The HLP and NHLP groups were compared for parameters of coagulation homeostasis, lipid metabolism, and disease severity. Correlations between disease severity and levels of D-dimer and protein C were investigated, and the prognostic potential of D-dimer was evaluated. RESULTS Compared with MAP patients, MSAP patients showed higher levels of D-dimer and lower levels of protein C. HLP patients had higher protein C levels than NHLP patients. Both D-dimer and protein C levels were significantly associated with the disease severity, not the disease etiology. D-dimer levels correlated positively with low density lipoprotein cholesterol levels and performed well as a sensitive and specific predictor of disease severity in AP patients, especially in HLP patients. CONCLUSIONS The coagulation homeostasis is different between HLP and NHLP patients, and HL may be a contributing factor for thrombosis and fibrinolysis in HLP. D-dimer may be a robust marker of disease severity in HLP.
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Affiliation(s)
- Ning Yang
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China.
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14
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Abstract
An international symposium entitled "Acute pancreatitis: progress and challenges" was held on November 5, 2014 at the Hapuna Beach Hotel, Big Island, Hawaii, as part of the 45th Anniversary Meeting of the American Pancreatic Association and the Japanese Pancreas Society. The course was organized and directed by Drs. Stephen Pandol, Tooru Shimosegawa, Robert Sutton, Bechien Wu, and Santhi Swaroop Vege. The symposium objectives were to: (1) highlight current issues in management of acute pancreatitis, (2) discuss promising treatments, (3) consider development of quality indicators and improved measures of disease activity, and (4) present a framework for international collaboration for development of new therapies. This article represents a compilation and adaptation of brief summaries prepared by speakers at the symposium with the purpose of broadly disseminating information and initiatives.
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15
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Miranda CJ, Mason JM, Babu BI, Sheen AJ, Eddleston JM, Parker MJ, Pemberton P, Siriwardena AK. Twenty-four hour infusion of human recombinant activated protein C (Xigris) early in severe acute pancreatitis: The XIG-AP 1 trial. Pancreatology 2015; 15:635-41. [PMID: 26547592 DOI: 10.1016/j.pan.2015.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/23/2015] [Accepted: 10/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Patients with severe acute pancreatitis were excluded from major trials of human recombinant activated protein C (Xigris) because of concern about pancreatic haemorrhage although these individuals have an intense systemic inflammatory response that may benefit from treatment. The object of this study was to provide initial safety data evaluating Xigris in severe acute pancreatitis. DESIGN Prospective clinical trial recruiting between November 2009 and October 2011. Patients received human recombinant activated protein C (Xigris) for 24 h by intravenous infusion (24 μg/kg/h) in addition to standard clinical care. A matched historical control group treated within the same hospital unit were used to compare outcomes. Of 166 consecutive admitted patients, 43 met the screening criteria for severe acute pancreatitis and 19 were recruited, all contributing to the analyses. RESULTS Compared to historical controls, there were fewer bleeding events in the Xigris group although the finding did not reach significance (Xigris 0% vs. Control 21%, p = 0.13), similarly further intervention appeared less frequent (11% vs. 47%, p = 0.07) in the treatment group. Length of stay was shorter for patients receiving Xigris (19 vs. 41 days, p = 0.03) as was inotrope use (5% vs. 32%, p = 0.02); mortality and incidence of infections in both groups were similar. Biomarker protein C increased while IL-6 decreased following infusion. CONCLUSIONS A 24-hr infusion of Xigris appears safe when used in patients with severe acute pancreatitis. TRIAL REGISTRATION Eudract Number 2007-003635-23.
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Affiliation(s)
- Charles J Miranda
- Hepatobiliary Surgical Unit, Manchester Royal Infirmary, Manchester, UK
| | - James M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Benoy I Babu
- Hepatobiliary Surgical Unit, Manchester Royal Infirmary, Manchester, UK
| | - Aali J Sheen
- Hepatobiliary Surgical Unit, Manchester Royal Infirmary, Manchester, UK
| | | | | | - Philip Pemberton
- Specialist Assay Laboratory, Manchester Royal Infirmary, Manchester, UK
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16
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Clinical Outcome of a Portosplenomesenteric Venous Thrombosis in Necrotizing Acute Pancreatitis with Protein C and S Deficiency Treated by Anticoagulation Therapy Alone. Case Rep Gastrointest Med 2015; 2015:934784. [PMID: 26448885 PMCID: PMC4581499 DOI: 10.1155/2015/934784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 08/24/2015] [Accepted: 08/30/2015] [Indexed: 12/05/2022] Open
Abstract
Cases of splanchnic venous thrombosis have not been described in Cameroon. Their prevalence in acute pancreatitis is variable. With the emergence of acute intra-abdominal infections including typhoid fever and peritoneal tuberculosis in situations of acquired immunodeficiency syndrome, these cases will become frequent. We report the case of a portosplenomesenteric venous thrombosis related to necrotizing acute pancreatitis associated with proteins C and S deficiency, in a 46-year-old Cameroonian man, without particular past medical history. He was admitted for abdominal pain which had been evolving for 3 weeks and accompanied by vomiting. In the absence of hemorrhagic risk factor, the patient received low molecular weight heparin followed by oral warfarin. The abdominal ultrasound check on the 12th day showed a partial recanalization of venous thrombosis. The abdominal contrast-enhanced CT scanner at day 30 on oral anticoagulation therapy showed collateral vessels and small bowel edema. At the same time the upper gastrointestinal endoscopy showed grade II esophageal varices. We have maintained oral anticoagulation therapy. This case highlights that an early effective anticoagulation heparin therapy is needed for a clear benefit in case of suspected PSMVT. It is certain that the sooner the treatment is given, the better outcome will be.
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17
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Kyhälä L, Lindström O, Kylänpää L, Mustonen H, Puolakkainen P, Kemppainen E, Tallgren M, Pettilä V, Repo H, Petäjä J. Activated protein C retards recovery from coagulopathy in severe acute pancreatitis. Scandinavian Journal of Clinical and Laboratory Investigation 2015; 76:10-6. [PMID: 26403265 DOI: 10.3109/00365513.2015.1084041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Activated protein C (APC), an endogenous anticoagulant, has antithrombotic, fibrinolytic and anti-inflammatory properties. We recently conducted a controlled study (APCAP, activated protein C in severe acute pancreatitis) of APC treatment of patients with severe acute pancreatitis (SAP). Here we studied the effect of APC on the pivotal coagulation parameters of the surviving patients in the APCAP study. METHODS The study consisted of 20 patients of whom 10 patients had received APC and 10 patients had received placebo. Coagulation parameters, physiological anticoagulants, thrombograms and circulating levels of IL-6 and CRP were determined on admission and at days 1, 3-4 and 6-7. RESULTS During follow-up, the temporal levels of prothrombin time (PT) decreased and the temporal levels of thromboplastin time (TT) increased in placebo group (p< 0.001 for both), but not in APC group. The temporal levels of antithrombin (AT) increased less in APC group than in placebo group (p = 0.011). The shapes of the SAP patients' thrombograms were strongly deranged and were marginally affected by APC treatment. CONCLUSIONS Coagulopathy in SAP, a complex phenomenon, is not alleviated by APC treatment. Rather, the patients receiving APC are heading toward normal homeostasis of coagulation slower than patients receiving placebo.
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Affiliation(s)
- Lea Kyhälä
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Outi Lindström
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Leena Kylänpää
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Harri Mustonen
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Pauli Puolakkainen
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Esko Kemppainen
- a Department of Surgery , University of Helsinki and Helsinki University Hospital , Helsinki
| | - Minna Tallgren
- b Intensive Care Units, Department of Anesthesia and Intensive Care Medicine , Helsinki University Central Hospital , Helsinki
| | - Ville Pettilä
- b Intensive Care Units, Department of Anesthesia and Intensive Care Medicine , Helsinki University Central Hospital , Helsinki
| | - Heikki Repo
- c Department of Bacteriology and Immunology , the Haartman Institute, University of Helsinki , Helsinki , and
| | - Jari Petäjä
- d Department of Gynecology and Pediatrics , Helsinki University Central Hospital , Helsinki , Finland
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18
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Eguchi T, Tsuji Y, Yamashita H, Fukuchi T, Kanamori A, Matsumoto K, Hasegawa T, Koizumi A, Kitada R, Tsujimae M, Iwatsubo T, Koyama S, Ubukata S, Fujita M, Okada A. Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients. Pancreatology 2015; 15:485-490. [PMID: 26320826 DOI: 10.1016/j.pan.2015.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/04/2015] [Accepted: 08/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.
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Affiliation(s)
- Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Yoshihisa Tsuji
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kawaramachi 54, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Hiroshi Yamashita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takumi Fukuchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Kei Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Takashi Hasegawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akio Koizumi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Ryuki Kitada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Masahiro Tsujimae
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Taro Iwatsubo
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Shintaro Koyama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Satoshi Ubukata
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Mikio Fujita
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata Kitaku, Osaka 530-0012, Japan.
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20
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Jeurnink SM, Nijs MM, Prins HAB, Greving JP, Siersema PD. Antioxidants as a treatment for acute pancreatitis: A meta-analysis. Pancreatology 2015; 15:203-8. [PMID: 25891791 DOI: 10.1016/j.pan.2015.03.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the efficacy of antioxidants in acute (AP) pancreatitis. METHODS We searched PubMed, Embase and the Cochrane library for all randomized controlled trials (RCT) involving administration of antioxidants in the therapy of AP until February 2012. AP studies were pooled to analyze the effect of antioxidants on hospital stay, mortality, and complications. Subgroup analyses were performed on the use of the antioxidant glutamine. RESULTS In total, eleven RCTs were included. Among patients with AP, antioxidant therapy resulted in a borderline significant reduction in hospital stay (mean difference -1.74; 95%CI -3.56 to 0.08), a significant decrease in complications (RR 0.66; 95%CI 0.46-0.95) and a non-significant decrease in mortality rate (RR 0.66; 95%CI 0.30-1.46). Subgroup analyses showed that glutamine significantly reduced complications (RR 0.51; 95%CI 0.34-0.78) and mortality rate (RR 0.33; 95%CI 0.13-0.85). CONCLUSION The present meta-analysis shows a possible benefit of glutamine supplementation in patients with acute pancreatitis. However, large randomized trials are needed to confirm these observations.
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Affiliation(s)
- S M Jeurnink
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
| | - M M Nijs
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - H A B Prins
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
| | - J P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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Kambhampati S, Park W, Habtezion A. Pharmacologic therapy for acute pancreatitis. World J Gastroenterol 2014; 20:16868-16880. [PMID: 25493000 PMCID: PMC4258556 DOI: 10.3748/wjg.v20.i45.16868] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/23/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
While conservative management such as fluid, bowel rest, and antibiotics is the mainstay of current acute pancreatitis management, there is a lot of promise in pharmacologic therapies that target various aspects of the pathogenesis of pancreatitis. Extensive review of preclinical studies, which include assessment of therapies such as anti-secretory agents, protease inhibitors, anti-inflammatory agents, and anti-oxidants are discussed. Many of these studies have shown therapeutic benefit and improved survival in experimental models. Based on available preclinical studies, we discuss potential novel targeted pharmacologic approaches that may offer promise in the treatment of acute pancreatitis. To date a variety of clinical studies have assessed the translational potential of animal model effective experimental therapies and have shown either failure or mixed results in human studies. Despite these discouraging clinical studies, there is a great clinical need and there exist several preclinical effective therapies that await investigation in patients. Better understanding of acute pancreatitis pathophysiology and lessons learned from past clinical studies are likely to offer a great foundation upon which to expand future therapies in acute pancreatitis.
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Ke L, Tong ZH, Li WQ, Wu C, Li N, Windsor JA, Li JS, Petrov MS. Predictors of critical acute pancreatitis: a prospective cohort study. Medicine (Baltimore) 2014; 93:e108. [PMID: 25380082 PMCID: PMC4616279 DOI: 10.1097/md.0000000000000108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Critical acute pancreatitis (CAP) has recently emerged as the most ominous severity category of acute pancreatitis (AP). As such there have been no studies specifically designed to evaluate predictors of CAP. In this study, we aimed to evaluate the accuracy of 4 parameters (Acute Physiology and Chronic Health Evaluation [APACHE] II score, C-reactive protein [CRP], D-dimer, and intra-abdominal pressure [IAP]) for predicting CAP early after hospital admission. During the study period, data on patients with AP were prospectively collected and D-dimer, CRP, and IAP levels were measured using standard methods at admission whereas the APACHE II score was calculated within 24 hours of hospital admission. The receiver-operating characteristic (ROC) curve analysis was applied and the likelihood ratios were calculated to evaluate the predictive accuracy. A total of 173 consecutive patients were included in the analysis and 47 (27%) of them developed CAP. The overall hospital mortality was 11% (19 of 173). APACHE II score ≥11 and IAP ≥13 mm Hg showed significantly better overall predictive accuracy than D-dimer and CRP (area under the ROC curve-0.94 and 0.92 vs. 0.815 and 0.667, correspondingly). The positive likelihood ratio of APACHE II score is excellent (9.9) but of IAP is moderate (4.2). The latter can be improved by adding CRP (5.8). In conclusion, of the parameters studied, APACHE II score and IAP are the best available predictors of CAP within 24 hours of hospital admission. Given that APACHE II score is rather cumbersome, the combination of IAP and CRP appears to be the most practical way to predict critical course of AP early after hospital admission.
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Affiliation(s)
- Lu Ke
- Department of General Surgery (LK, ZT, WL, CW, NL, JL), Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; and Department of Surgery (JAW, MSP), University of Auckland, Auckland, New Zealand
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Acute and chronic pancreatic inflammation. Int J Inflam 2013; 2012:481658. [PMID: 23346459 PMCID: PMC3549349 DOI: 10.1155/2012/481658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/11/2012] [Indexed: 11/25/2022] Open
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The clinical course of acute pancreatitis and the inflammatory mediators that drive it. Int J Inflam 2012; 2012:360685. [PMID: 23304633 PMCID: PMC3530799 DOI: 10.1155/2012/360685] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 11/09/2012] [Accepted: 11/15/2012] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis (AP) is a common emergency condition. In the majority of cases, it presents in a mild and self-limited form. However, about 20% of patients develop severe disease with local pancreatic complications (including necrosis, abscess, or pseudocysts), systemic organ dysfunction, or both. A modern classification of AP severity has recently been proposed based on the factors that are causally associated with severity of AP. These factors are both local (peripancreatic necrosis) and systemic (organ failure). In AP, inflammation is initiated by intracellular activation of pancreatic proenzymes and/or nuclear factor-κB. Activated leukocytes infiltrate into and around the pancreas and play a central role in determining AP severity. Inflammatory reaction is first local, but may amplify leading to systemic overwhelming production of inflammatory mediators and early organ failure. Concomitantly, anti-inflammatory cytokines and specific cytokine inhibitors are produced. This anti-inflammatory reaction may overcompensate and inhibit the immune response, rendering the host at risk for systemic infection. Currently, there is no specific treatment for AP. However, there are several early supportive treatments and interventions which are beneficial. Also, increasing the understanding of the pathogenesis of systemic inflammation and the development of organ dysfunction may provide us with future treatment modalities.
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Treatment of necrotizing pancreatitis. Clin Gastroenterol Hepatol 2012; 10:1190-201. [PMID: 22610008 DOI: 10.1016/j.cgh.2012.05.005] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/25/2012] [Accepted: 05/07/2012] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis is a common and potentially lethal disease. It is associated with significant morbidity and consumes enormous health care resources. Over the last 2 decades, the treatment of acute pancreatitis has undergone fundamental changes based on new conceptual insights and evidence from clinical studies. The majority of patients with necrotizing pancreatitis have sterile necrosis, which can be successfully treated conservatively. Emphasis of conservative treatment is on supportive measures and prevention of infection of necrosis and other complications. Patients with infected necrosis generally need to undergo an intervention, which has shifted from primary open necrosectomy in an early disease stage to a step-up approach, starting with catheter drainage if needed, followed by minimally invasive surgical or endoscopic necrosectomy once peripancreatic collections have sufficiently demarcated. This review provides an overview of current standards for conservative and invasive treatment of necrotizing pancreatitis.
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Abstract
PURPOSE OF REVIEW In this article, recent advances in the pathogenesis of acute pancreatitis have been reviewed. RECENT FINDINGS Pathologic intra-acinar trypsinogen activation had been hypothesized to be the central mechanism of pancreatitis for over a century. This hypothesis could be explored for the first time with the development of a novel mouse model lacking pathologic intra-acinar trypsinogen activation. It became clear that intra-acinar trypsinogen activation contributes to early acinar injury, but local and systemic inflammation progress independently during pancreatitis. Early intra-acinar nuclear factor kappa B (NFκB) activation, which occurs parallel to but independent of trypsinogen activation, may be crucial in pancreatitis. Although the mechanism of NFκB and trypsinogen activation is not entirely clear, further insights have been made into key pathogenic cellular events such as calcium signaling, mitochondrial dysfunction, endoplasmic reticulum (ER) stress, autophagy and impaired trafficking, and lysosomal and secretory responses. Cellular intrinsic damage-sensing mechanisms that lead to activation of the inflammatory response aimed at repair, but lead to disease when overwhelmed, are beginning to be understood. SUMMARY New findings necessitate a paradigm shift in our understanding of acute pancreatitis. Intra-acinar trypsinogen activation leads to early pancreatic injury, but the inflammatory response of acute pancreatitis develops independently, driven by early activation of inflammatory pathways.
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Activated Protein C Does Not Alleviate the Course of Systemic Inflammation in the APCAP Trial. Int J Inflam 2012; 2012:712739. [PMID: 22645700 PMCID: PMC3356881 DOI: 10.1155/2012/712739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 02/20/2012] [Indexed: 12/22/2022] Open
Abstract
The study aimed to determine the effect of the activated protein C on the course of systemic inflammation in the APCAP (activated protein C in acute pancreatitis) trial where we randomized 32 patients with severe acute pancreatitis to receive either recombinant activated protein C (drotrecogin alfa activated) (n = 16) or placebo (n = 16) for 96 hours. In the present study, we present the time course of the patients' plasma or serum levels of soluble markers (IL-8, IL-6, IL-10, IL-1ra, sE-selectin, PCT) and monocyte and neutrophil cell surface (CD11b, CD14, CD62L, HLA-DR) markers of systemic inflammatory response during the first 14 days after the randomization. The results of the intervention and placebo groups were comparable showing that recombinant APC treatment did not alter the course of systemic inflammation in severe acute pancreatitis. Our finding is in accordance with the clinical findings in the APCAP trial indicating that the intervention did not affect evolution of multiple organ dysfunctions.
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Miranda CJ, Babu BI, Siriwardena AK. Recombinant human activated protein C as a disease modifier in severe acute pancreatitis: systematic review of current evidence. Pancreatology 2012; 12:119-23. [PMID: 22487521 DOI: 10.1016/j.pan.2012.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The severity of organ failure caused by acute pancreatitis (AP) is the most important determinant of mortality in the disease. Recombinant human activated protein C (Drotrecogin Alfa; Xigris, APC, rhAPC) is the first drug to show a decrease in all-cause mortality due to multiple organ failure caused by sepsis. As the systemic inflammatory response syndrome (SIRS) that causes organ failure in early AP is similar to that caused by severe sepsis, the use of rhAPC in the management of AP has been investigated in experimental and clinical studies which are collated in this review. METHODS A literature review of published material identified from MEDLINE and EMBASE databases, for the period from January 1985 to January 2011, reporting rhAPC usage in AP. RESULTS 3 of 4 experimental studies reported an improvement in outcome in animals with AP given rhAPC. The clinical randomized trial showed no improvement in outcome in the treatment arm. CONCLUSION The experimental evidence of disease amelioration in AP following intervention with rhAPC has not translated to the small clinical RCT. Given that there were only 16 patients in the treatment arm, further clinical evaluation is justified.
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Affiliation(s)
- Charles J Miranda
- Hepatobiliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Abstract
PURPOSE OF REVIEW Despite being a subject of much scientific scrutiny, the pathogenesis of acute pancreatitis is still not well understood. This article reviews recent advances in our understanding of acute pancreatitis. RECENT FINDINGS Zymogen activation, observed within acini early during acute pancreatitis for a long time, was shown to be sufficient to induce acute pancreatitis. Another key early event, NFκB activation, has previously been shown to induce acute pancreatitis. The relationship between these two key early steps is beginning to be clarified. Mechanisms of zymogen activation - pathologic calcium signaling, pH changes, colocalization and autophagy, and of NFκB activation have been investigated intensively along with potential therapeutic targets both upstream and downstream of these key events. Additional key findings have been elucidation of the role of bioenergetics and the dual role of oxidative stress in acute pancreatitis, recognition of endoplasmic reticulum stress as an early step and the status of duct cells as important entities in pancreatic injury. SUMMARY Current findings have provided further insight into the roles and mechanisms of zymogen activation and inflammatory pathways in pancreatic injury. Future studies, which will be of great importance in identifying therapeutic targets, are being undertaken to establish the relative contributions of these pathways during acute pancreatitis.
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Abstract
Significant literature on the management of acute severe acute pancreatitis has emerged in recent years. The new information ranges from data on newer single or multiparameter severity assessment tools and classification systems to therapeutic modalities. However, a few basic issues-the ideal severity assessment modality, volume of intravenous fluids required in the first 48 to 72 h, and the role of prophylactic antibiotics-are still not clear and are subject to controversy. The International Working Group has devised the Revised Atlanta Classification, which will be published soon. This new classification is eagerly awaited worldwide, and hopefully clarifies many of the problems of the original Atlanta Classification. In this article, we discuss the developments that have arisen in the past 2 to 3 years concerning the classification, prognostication, and early management of severe acute pancreatitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Miles and Shirley Fiterman Center for Digestive Diseases, 200 First Street SW, Mayo Clinic, Rochester, MN 55905, USA.
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Shankar-Hari M, Wyncoll D. Activated protein C in severe acute pancreatitis without sepsis? Not just yet ... CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:188. [PMID: 20707935 PMCID: PMC2945109 DOI: 10.1186/cc9190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Severe acute pancreatitis (SAP) is characterized by an unregulated systemic proinflammatory response secondary to activation of trypsin within the pancreatic tissue, resulting in multiple organ failure. This dysregulated inflammation leading to organ dysfunction also characterizes severe sepsis. Activated protein C (APC) has pleotropic effects on the immune, coagulation, inflammatory and apoptotic pathways, and has been postulated to benefit acute pancreatitis - although concerns of possible retroperitoneal bleeding remain. Currently, experimental studies and subgroup data on patients with pancreatitis from a randomized controlled trial of APC in severe sepsis form the literature on the possible role of APC in SAP. We review the first randomized controlled trial of APC in acute pancreatitis published in the present issue of Critical Care.
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