Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment

Effects of gut microbiota and metabolites on pancreatitis: a 2-sample Mendelian randomization study

BACKGROUND

Acute pancreatitis (AP) and chronic pancreatitis (CP) have high incidences and poor prognoses. The early screening of at-risk populations still awaits further study. The limitation was mainly based on observational studies, with limited sample size and the presence of confounding factors. This study used a 2-sample Mendelian randomization (MR) analysis based on publicly available data from genome-wide association studies to reveal the causal effect of gut microbiota and metabolites on pancreatitis.

METHODS

This study collected summary statistics on gut microbiota, metabolites, AP, and CP. A 2-sample MR analysis was performed using MR-Egger, inverse variance-weighted, MR Pleiotropy RESidual Sum and Outlier, maximum likelihood, and weighted median.

RESULTS

The 2-sample MR showed that only Eubacterium coprostanoligenes was an independent protective factor for AP among all gut microbiota, and the other microbiota were not significant for pancreatitis. Unsaturated fatty acids in metabolites are protective factors for both AP (odds ratio [OR], 0.730; 95% CI, 0.593-0.899; P = .003) and CP (OR, 0.660; 95% CI, 0.457-0.916; P = .013). Furthermore, carnitine was a protective factor CP, and glucose was an independent risk factor for CP.

CONCLUSION

This study provides potential evidence of the causal role of gut microbiota and metabolites on pancreatitis, which may be conducive for designing microbiome and metabolite interventions on AP or CP in the future.

Sex-dependent modulation of caerulein-induced acute pancreatitis in C57BL/6J mice

Acute pancreatitis (AP) is a life-threatening condition, with a higher mortality rate in men than women and in which estrogens might play a protective role. This study aimed to investigate sex-dependent differences in a mouse model of caerulein-induced AP. Thirty-six C57BL/6J mice (19 females and 17 males) were treated intraperitoneally with phosphate-buffered saline or caerulein, and sacrificed 12 hours, 2 days, or 7 days after the last injection. Blood was collected for amylase, lipase, and glucose determination. Severity and extent of inflammation, apoptosis, and acinar to ductal metaplasia (ADM) in pancreatic tissue were scored histologically and total macrophages, major histocompatibility complex (MHC)-II+ cells, M2 macrophages, T and B cells, neutrophils, apoptosis, and ADM were marked immunohistochemically and quantified by digital image analysis. Serum amylase had a peak at 12 hours, without differences between the sexes. In females, pancreatitis reached a peak at 12 hours with a fast recovery while, in males, the peak was delayed to day 2 with residual apoptosis still present. Macrophages were the main inflammatory cell population, followed by T cells, B cells and neutrophils, without differences between sexes. In males, CD206+ cells and apoptosis were higher at both days 2 and 7, and cytokeratin-19+ (CK19+) ADM was higher at day 7 compared with females. The results of this study revealed a faster onset and resolution of caerulein-induced AP in female mice compared with male mice, supporting a sex-dependent modulation of acute pancreatitis.

Risk score to predict inpatient mortality of acute pancreatitis patients admitted to the intensive care unit

BACKGROUND/OBJECTIVES

Predicting inpatient mortality for acute pancreatitis (AP) patients in the ICU is crucial for optimal treatment planning. This study aims to develop a concise risk score model for this purpose, enhancing the predictability and management of AP in ICU settings.

METHODS

We included 380 patients in our training set. Twenty-seven variables were retrospectively collected, and predictive variables were selected using LASSO penalized regression and refined through backward elimination multivariate models. Effect sizes were used to create the final model to predict 7 and 30-day mortality among AP patients admitted to the ICU.

RESULTS

Of 380 patients, the mortality rate was 23.2 %. The final model included five predictors: INR, Albumin, Lactic Acid, BUN, and Bilirubin. The 5-fold cross-validated mean AUC was 0.93 (SD: 0.048) for 7-day mortality and 0.84 (SD: 0.033) for 30-day mortality, with a sensitivity of 77 % and specificity of 74 %. The risk score outperformed BISAP (AUC: 0.60) and APACHE-II (AUC: 0.76) in predicting mortality.

CONCLUSION

Our model offers a convenient tool using commonly available laboratory results to predict mortality among AP patients, with potential applicability in both ICU settings.

Acute Pancreatitis Caused by Tirzepatide

Glucagon-like peptide-1 (GLP-1) receptor agonists, including tirzepatide (Mounjaro), are widely used to manage type 2 diabetes mellitus (T2DM) and obesity. While gastrointestinal side effects are common, acute pancreatitis remains a rare but significant complication. Limited evidence exists on the risks associated with switching between GLP-1 agonists, emphasizing the need for clinical awareness. We present a 59-year-old male with T2DM, hyperlipidemia, and hypertension, who was recently transitioned from semaglutide (Ozempic) to tirzepatide (Mounjaro). He presented with acute epigastric pain, nausea, and vomiting two days after initiating tirzepatide. Laboratory findings revealed elevated lipase levels (847 U/L), leukocytosis, and diagnostic imaging confirming acute pancreatitis with other causes ruled out. Supportive care improved symptoms initially, but the clinical course was complicated by fevers prompting repeat imaging, revealing worsening pancreatitis with colonic involvement and pleural effusion. The patient was treated with empiric antibiotics and supportive measures, resulting in resolution of symptoms. Tirzepatide was discontinued, with a follow-up arranged for glycemic management. Acute pancreatitis is a rare but documented adverse effect of GLP-1 agonists, with limited cases reported in the literature. Switching between GLP-1 agonists may increase the risk of adverse effects, especially if appropriate dose titration protocols are not followed. This case highlights the recognition of acute pancreatitis as a potential adverse effect of GLP-1 agonists when initiating or transitioning GLP-1 therapies and following titration protocols to help avoid this complication. GLP-1 agonists, including tirzepatide, offer significant therapeutic benefits for T2DM and obesity but carry risks of rare adverse effects like acute pancreatitis. Greater awareness, careful dose adjustments, and vigilant monitoring are essential to optimizing patient safety. Further research is needed to elucidate the safety profile of switching between GLP-1 agonists to guide clinical practice and improve patient outcomes.

The molecular mechanism of PLD2-mediated regulation of apoptosis and cell edema in pancreatic cells via the Nrf2/NF-κB pathway

This study aimed to elucidate the molecular mechanisms by which PLD2 controls apoptosis and edema in pancreatic cells via the Nrf2/NF-κB pathway. AR42J rat pancreatic cells were treated with 10 nM mitomycin to create an in vitro pancreatitis model (model group), with a control group receiving phosphate-buffered saline. Cells were transfected with a PLD2 overexpression plasmid using Lipofectamine 3000, forming the PLD2 overexpression group. PLD2 protein expression was assessed by Western blotting, and TNF-α, IL-6, and IL-10 levels were measured by RT-qPCR. Nrf2/NF-κB protein expressions were also analyzed. Apoptosis and necrosis were evaluated using Annexin V-FITC/PI staining and the LDH release test. Cell edema was assessed by cell volume, ion content, and membrane damage. Western blotting was used to analyze pan-apoptosis-related proteins. PLD2 expression was lower in the model group compared to controls (P < 0.05) but higher in the PLD2 overexpression group (P < 0.05). TNF-α, IL-6, and IL-10 levels were elevated in the model group (P < 0.05) and reduced in the PLD2 overexpression group (P < 0.05). Nrf2 expression decreased in the model group but increased with PLD2 overexpression (P < 0.05). NF-κB expression increased in the model group but decreased with PLD2 overexpression (P < 0.05). Apoptosis and necrosis rates were higher in the model group (P < 0.05) but lower in the PLD2 overexpression group (P < 0.05). Cell volume, Na + content, and LDH release increased in the model group (P < 0.05) but decreased with PLD2 overexpression (P < 0.05). RIPK1 expression decreased in the model group (P < 0.05) but increased with PLD2 overexpression (P < 0.05). CASP8, FADD, and ZBP1 levels were higher in the model group (P < 0.05) and reduced with PLD2 overexpression (P < 0.05). PLD2 exerts a protective effect in acute pancreatitis by activating Nrf2 and inhibiting NF-κB, reducing apoptosis, cell swelling, and membrane damage. This highlights potential therapeutic targets for pancreatic inflammation.

Relevance of Procalcitonin Levels as a Marker of Severity and Predictor of Mortality, Initiation and Duration of Antibiotics in Patients Admitted with Acute Pancreatitis: A Retrospective Cohort Study

Introduction

Procalcitonin levels have been studied to predict the benefit of adding antibiotics in a patient with acute pancreatitis. Through this study, we are searching for any possible correlation between serum procalcitonin levels and the severity of acute pancreatitis (included acute on chronic cases) to determine whether procalcitonin levels can predict a benefit from antibiotic therapy in acute pancreatitis.

Methods

This is a retrospective cohort study involving patients with acute pancreatitis and acute on chronic pancreatitis. We included all hospitalized patients admitted to Kern Medical from January 2020 to October 2022 with a diagnosis of acute pancreatitis in a consecutive manner. The primary outcome studied was mortality related to the pancreatitis episode. Logistic regression was used to control numerous confounders.

Results

Based on univariate analysis of procalcitonin, we found starting antibiotics on the day of admission statistically significant. We also found the median differences in mortality to be mildly significant (difference = 0.79, p = 0.0640) based on procalcitonin values. In a multivariate analysis of ln(procalcitonin), we found lipase (p = 0.0249), duration of antibiotics (p = 0.0009), multi-organ failure (p = 0.0045) to be statistically significant, and lactate being mildly significant in the multivariate model (p = 0.0643).

Conclusion

The procalcitonin level can predict the initiation of antibiotics, duration of antibiotics, multi-organ failure, and mortality in patients with acute pancreatitis.

Epigenetic alterations dictating the inflammation: A view through pancreatitis

Pancreatitis is a severe inflammation in the pancreas and accounts for one of the leading gastrointestinal disorders worldwide, and presently pacing up with the morbidity and mortality rates. It has been noted that severe recurrences of acute pancreatitis lead to chronic inflammation and fibrosis of the pancreas which may further result to a long-term risk of pancreatic carcinogenesis which has a lower survival rate and worse prognosis. Several genetic and epigenetic mechanisms have been reported to orchestrate disease development. Intriguingly, concurrent epigenetic alterations can also control the genes responsible for the pathophysiology of several inflammatory pathways. Deciphering how epigenetic changes affect the inflammatory processes in pancreatitis and body's response to various therapeutic modalities may help to manage the condition more effectively. The current review will concentrate on several epigenetic changes in general and how specifically they are implicated in pancreatitis pathogenesis. Further, this review summarizes the involvement of inflammation in pancreatitis from an epigenetic perspective.

Zerumbone ameliorates the inflammatory response and organ damage in severe acute pancreatitis via the ROS/NF-κB pathway

OBJECTIVE

The aim of the current study was to determine the mechanism by which Zerumbone (ZER) ameliorates inflammation and organ damage in a rat model of severe acute pancreatitis (SAP).

METHODS

Different concentrations of ZER (10, 20 and 40 mg/kg) were administered by femoral vein puncture 30 min prior to establishment of the SAP model. Hematoxylin and eosin (H&E) staining was used to assess pathological changes in the pancreatic tissue of SAP-induced rats. The lung wet/dry (W/D) ratio was assessed and serum levels of amylase (AMY), alanine aminotransferase (ALT), creatinine (Cr), aspartate aminotransferase (AST) and phospholipase A2 (PLA2) were measured. Western blot analysis was used to examine changes in the expression of ROS/NF-κB pathway-associated proteins.

RESULTS

SAP was confirmed by significant histopathological damage to the pancreas. ZER (10, 20 and 40 mg/kg) was found to alleviate pancreatitis and decrease ascites volume, lung W/D ratio, pancreatic pathology score, oxidative stress and inflammatory damage. High concentrations (20 and 40 mg/kg) of ZER were shown to increase levels of hepatorenal toxicity. In contrast, 10 mg/kg ZER was found to attenuate liver enzyme levels, reduce pathological damage to the liver, and protect against extrapancreatic organ damage to the liver in SAP-induced rats. Moreover, ZER showed no significant side effects in normal rats. Finally, we demonstrated that ZER mediated its anti-inflammatory effects on SAP through the ROS/NF-κB signaling pathway.

CONCLUSION

ZER alleviated SAP-induced oxidative stress and inflammatory injury via the ROS/NF-κB pathway, and had a protective effect on lung injury and liver damage.

Potential value of red blood cell distribution width in predicting in-hospital mortality in intensive care US population with acute pancreatitis: a propensity score matching analysis

The association between red blood cell distribution width (RDW) and in-hospital mortality in intensive care patients with acute pancreatitis (AP) is inconclusive. We extracted the baseline data, Bedside Index for Severity in Acute Pancreatitis (BISAP) score, Sequential Organ Failure Assessment (SOFA) score, and in-hospital prognosis of intensive care patients with AP from the Medical Information Mart for Intensive Care IV database. Performing binary logistic regression analysis to determine whether RDW is an independent risk factor for in-hospital mortality. By drawing receiver operating characteristic (ROC) curves and comparing the areas under the ROC curves (AUC) to determine the predictive value of RDW for in-hospital mortality, and by conducting survival analysis to evaluate the impact of RDW on survival time in hospital. Before and after the propensity score matching (PSM) analysis, RDW was always a risk factor for in-hospital mortality in patients with AP. The AUC of RDW was comparable to BISAP, while the AUCs of combining RDW and BISAP or SOFA were greater than that of BISAP or SOFA alone. The median survival time of the high-RDW group (RDW > 15.37%, before PSM; RDW > 15.35%, after PSM) was shorter than that of the low-RDW group. Compared with the low-RDW group, the hazard ratios of the high-RDW group were 3.0708 (before PSM) and 1.4197 (after PSM). RDW is an independent risk factor for in-hospital mortality in patients with AP. The predictive value of RDW for in-hospital mortality of patients with AP is comparable to BISAP, and the combination of RDW and BISAP or SOFA scoring system can improve the predictive performance to a certain extent.

The effects of continuous renal replacement therapy with different anticoagulation methods on the expression of cytokines in severe acute pancreatitis

OBJECTIVE

Severe acute pancreatitis (SAP) is a highly morbid condition in general population as well as in solid organ transplant (SOT) recipients. The present study aimed to investigate the effect of continuous renal replacement therapy (CRRT) with different anticoagulation methods on the expression levels of cytokines in SAP.

METHODS

A total of 120 patients with SAP, admitted into our hospital between September 2017 and July 2020, were enrolled as the research subjects and randomly divided into a control group (60 cases) and a study group (60 cases). CRRT with low molecular weight (LMW) heparin‑calcium anticoagulation was conducted on patients in the control group, and CRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation was conducted on patients in the study group. The expressions of cytokines in the two groups were compared after treatment.

RESULTS

There was no significant difference in white blood cells (WBC), C-reactive proteins (CRP), and procalcitonin (PCT) before treatment between the two groups (P > 0.05). After treatment, the levels of WBC (P = 0.006), CRP (P < 0.001), and PCT (P < 0.001) were significantly lower in the study group when compared with those in the control group. There was no significant difference in the concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) between the two groups before treatment (P > 0.05). After treatment, the concentrations of IL-6, IL-8, and TNF-α were significantly lower in the study group when compared with those in the control group. The APACHEII, SOFA and Ranson scores of the two groups were analyzed, and there was no difference between the two groups before treatment (P > 0.05). After treatment, the score of the study group was lower than that of the control group (P < 0.05).

CONCLUSION

CRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation in the treatment of patients with SAP reduces the levels of WBC, CRP, and PCT and the concentrations of cytokines, including IL-6, IL-8, and TNF-α. This inhibits the release of inflammatory mediators in patients with SAP and reduces damage to the body caused by the inflammatory response, thus effectively improving the patients' condition.

The association between hypertension and the risk of gallstone disease: a cross-sectional study

BACKGROUND

To explore the association between hypertension and the risk of gallstone disease.

METHODS

We collected the data about the subjects receiving physical examination. Gallstone disease was diagnosed by abdominal ultrasound. Multivariable logistic regression was used to study the association between blood pressure and the risk of gallstone disease. SPSS version 23.0 was used for statistical analysis, and two-tailed P < 0.05 was defined as statistically significant.

RESULTS

A total of 318,403 people were included in the study and 171,276 (53.8%) of them were men and 147,127 (46.2%) were women. Among them, 27,463 (8.6%) were diagnosed with gallstone disease on ultrasound examination, with 12,452 (3.9%) cases of gallstones and 15,017 (4.7%) cases of cholecystectomy. Multivariable logistic regression showed that hypertension was significantly associated with the risk of gallstone disease (OR = 1.05; 95% CI: 1.02-1.10; P = 0.03) and gallstones (OR = 1.12; 95% CI: 1.06-1.19; P < 0.01) and the association between hypertension and gallstone disease was stronger in women than in men. However, hypertension was not significantly correlated with cholecystectomy (OR = 0.99; 95% CI: 0.95-1.04; P = 0.85). Additionally, results showed that with the severity of hypertension increased, the risk of gallstone disease was also marked elevated (P for trend < 0.001).

CONCLUSIONS

The gallstone disease was prevalent and hypertension is significantly associated with the gallstone disease risk with a significant dose-response association. This study showed that the association between hypertension and cholecystectomy was not statistically significant, maybe hypertension correlated with gallstones but not with symptomatic gallstone disease which would require cholecystectomy.

A Novel Risk-Prediction Scoring System for Sepsis among Patients with Acute Pancreatitis: A Retrospective Analysis of a Large Clinical Database

Background

The prognosis is poor when acute pancreatitis (AP) progresses to sepsis; therefore, it is necessary to accurately predict the probability of sepsis and develop a personalized treatment plan to reduce the disease burden of AP patients.

Methods

A total of 1295 patients with AP and 43 variables were extracted from the Medical Information Mart for Intensive Care (MIMIC) IV database. The included patients were randomly assigned to the training set and to the validation set at a ratio of 7 : 3. The chi-square test or Fisher's exact test was used to test the distribution of categorical variables, and Student's t-test was used for continuous variables. Multivariate logistic regression was used to establish a prognostic model for predicting the occurrence of sepsis in AP patients. The indicators to verify the overall performance of the model included the area under the receiver operating characteristic curve (AUC), calibration curves, the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), and a decision curve analysis (DCA).

Results

The multifactor analysis results showed that temperature, phosphate, calcium, lactate, the mean blood pressure (MBP), urinary output, Glasgow Coma Scale (GCS), Charlson Comorbidity Index (CCI), sodium, platelet count, and albumin were independent risk factors. All of the indicators proved that the prediction performance and clinical profitability of the newly established nomogram were better than those of other common indicators (including SIRS, BISAP, SOFA, and qSOFA).

Conclusions

The new risk-prediction system that was established in this research can accurately predict the probability of sepsis in patients with acute pancreatitis, and this helps clinicians formulate personalized treatment plans for patients. The new model can reduce the disease burden of patients and can contribute to the reasonable allocation of medical resources, which is significant for tertiary prevention.

Pleural effusion volume in patients with acute pancreatitis: a retrospective study from three acute pancreatitis centers

OBJECTIVE

To assess the value of pleural effusion volume (PEV) quantified on chest computed tomography (CT) in patients with early stage acute pancreatitis (AP).

METHODS

Data of PEV, and C-reactive protein (CRP) levels as well as Ranson, bedside index of severity in acute pancreatitis (BISAP), Marshall, acute physiology and chronic health evaluation II (APACHE II), CT severity index (CTSI), and extra-pancreatic inflammation on computed tomography (EPIC) scores in patients with AP were collected. Duration of hospitalization, severity of AP, infection, procedure, intensive care unit (ICU) admission, organ failure, or death were included as the outcome parameters.

RESULTS

In 465 patients, the mean PEV was 98.8 ± 113.2 mL. PEV showed strong and significant correlations with the CRP levels, duration of hospitalization as well as the Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scores (p < .05). PEV demonstrated significant accuracy in predicting severity, infection, procedure, ICU admission, organ failure, and death (p < .05).

CONCLUSION

PEV quantified on chest CT positively associated with the duration of hospitalization, CRP levels, Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scores. It can be a reliable radiologic biomarker in predicting severity and clinical outcomes of AP.KEY MESSAGESPleural effusion is a common chest finding in patients with acute pancreatitis.Pleural effusion volume quantified on chest CT examination positively associated with the duration of hospitalization, CRP level, as well as Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scoring systems.Pleural effusion volume can be a reliable radiologic biomarker in the prediction of severity and clinical outcomes of acute pancreatitis.

Long Non-coding RNA FENDRR Modulates Autophagy Through Epigenetic Suppression of ATG7 via Binding PRC2 in Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory, complicated pancreatic disease, carrying significant morbidity and mortality. However, the molecular and cellular mechanisms involved in AP pathogenesis remain to be elucidated. Here, we explore the role of FOXF1 adjacent non-coding developmental regulatory RNA (FENDRR) in AP progression. Caerulein with or without LPS- induced or taurolithocholic acid 3-sulfate (TLC-S)-induced AP mouse models and cell models were performed for the validation of FENDRR expression in vivo and in vitro, respectively. Histopathological examinations of pancreatic tissues were performed to evaluate the severity of AP. Transmission electron microscopy was utilized to visualize the autophagic vacuoles. siRNA specifically targeting FENDRR was further applied. Flow cytometry was employed to assess cell apoptosis. ELISA, immunoflureoscence, and western blotting analysis were also performed to determine the levels of inflammatory cytokines and autophagy activity. RNA immunoprecipitation (RIP) and chromatin immunoprecipitation (ChIP) assays were carried out to reveal the epigenetic regulation of FENDRR on ATG7. Additionally, silencing FENDRR was also verified in AP mouse models. Higher FENDRR and impaired autophagy were displayed in both AP mouse models and cell models. FENDRR knockdown dramatically attenuated caerulein- or TLC-S-induced AR42J cells apoptosis and autophagy suppression. Further mechanistic experiments implied that the action of FENDRR is moderately attributable to its repression of ATG7 via direct interaction with the epigenetic repressor PRC2. Moreover, the silencing of FENDRR significantly induced the promotion of ATG7, thus alleviating the development of AP in vivo. Our study highlights FENDRR as a novel target that may contribute to AP progression, suggesting a therapeutic target for AP treatment.

Selective inhibition of soluble TNF using XPro1595 relieves pain and attenuates cerulein-induced pathology in mice

Background

Symptoms associated with acute pancreatitis can be debilitating, and treatment remains a challenge. This study aimed to investigate the efficacy of selectively inhibiting the soluble form of TNF (solTNF) using the biologic XPro1595 in a mouse model of acute pancreatitis.

Methods

Acute pancreatitis was induced in adult male C57Bl/6J mice by administering cerulein (8 injections of 50 µg/kg I.P., spaced an hour apart), with XPro1595 (10 mg/kg, S.C.) or vehicle being administered approximately 18 h after the last injection. Serum was collected 6 or 18 h after the last cerulein injection, pancreatic tissue was collected 2 and 7 days post-induction, and brain hippocampal tissue was collected at 7 days post-induction. The animal’s pain level was assessed 3, 5 and 7 days post-induction.

Results

The induction of acute pancreatitis promoted a strong increase in serum amylase levels, which had receded back to baseline levels by the next morning. XPro1595 treatment began after amylase levels had subsided at 18 h, and prevented pancreatic immune cell infiltration, that subsequently prevented tissue disruption and acinar cell death. These improvements in pathology were associated with a significant reduction in mechanical hypersensitivity (neuropathic pain). XPro1595 treatment also prevented an increase in hippocampal astrocyte reactivity, that may be associated with the prevention of neuropathic pain in this mouse model.

Conclusion

Overall, we observed that selectively inhibiting solTNF using XPro1595 improved the pathophysiological and neurological sequelae of cerulein-induced pancreatitis in mice, which provides support of its use in patients with pancreatitis.

Efficacy of Xuebijing Injection for Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

METHODS

PubMed Medline, Embase, Cochrane Library, China National Knowledge Infrastructure, China Biology Medicine disc, VIP, and Wanfang databases were searched. The primary outcome was treatment response. The secondary outcomes included changes in clinical and laboratory indicators and incidence of AP-related complications. Meta-analyses were performed by using a random-effect model. Risk ratios (RRs) with 95% confidence intervals (CIs) or weighted mean differences (WMDs) with 95% CIs were calculated.

RESULTS

Overall, 23 RCTs were included. The rates of overall (RR = 1.16; 95% CI = 1.12 to 1.20; P < 0.00001) and complete (RR = 1.40; 95% CI = 1.30 to 1.50; P < 0.00001) responses were significantly higher in the Xuebijing injection group. After treatment, the levels of interleukin-6 (WMD = -18.22; 95% CI = -23.36 to -13.08; P < 0.00001), tumor necrosis factor-α (WMD = -16.44; 95% CI = -20.49 to -12.40; P < 0.00001), serum amylase (WMD = -105.61; 95% CI = -173.77 to -37.46; P=0.002), white blood cell (WMD = -1.51; 95% CI = -1.66 to -1.36; P < 0.00001), and C-reactive protein (WMD = -11.05; 95% CI = -14.32 to -7.78; P < 0.00001) were significantly lower in the Xuebijing injection group. Abdominal pain (WMD = -1.74; 95% CI = -1.96 to -1.52; P < 0.00001), abdominal distension (WMD = -1.56; 95% CI = -2.07 to -1.04; P < 0.00001), gastrointestinal function (WMD = -2.60; 95% CI = -3.07 to -2.13; P < 0.00001), body temperature (WMD = -2.16; 95% CI = -2.83 to -1.49; P < 0.00001), serum amylase level (WMD = -1.81; 95% CI = -2.66 to -0.96; P < 0.0001), and white blood cell (WMD = -2.16; 95% CI = -2.99 to -1.32; P < 0.00001) recovered more rapidly in the Xuebijing injection group. The incidence of multiple organ dysfunction syndrome (RR = 0.18; 95% CI = 0.05 to 0.62; P=0.006), pancreatic pseudocyst (RR = 0.17; 95% CI = 0.04 to 0.77; P=0.02), and renal failure (RR = 0.16; 95% CI = 0.05 to 0.60; P=0.006) was significantly lower in the Xuebijing injection group.

CONCLUSIONS

Xuebijing injection added on the basis of conventional treatment has a potential benefit for improving the outcomes of AP.

Mesna Alleviates Cerulein-Induced Acute Pancreatitis by Inhibiting the Inflammatory Response and Oxidative Stress in Experimental Rats

BACKGROUND

Acute pancreatitis (AP) is a sudden inflammation of the pancreas that may be life-threatening disease with high mortality rates, particularly in the presence of systemic inflammatory response and multiple organ failure. Oxidative stress has been shown to be involved in the pathophysiology of acute pancreatitis.

AIM

This study is designed to investigate the possible effect of mesna on an experimental model of cerulein-induced acute pancreatitis.

METHODS

Animals were divided into five groups: Group 1 served as a control group given the saline; group II (mesna group) received mesna at a dose of (100 mg/kg per dose, i.p.) four times; group III (acute pancreatitis group) received cerulein at a dose of (20 µg/kg/dose, s.c.) four times with 1-h intervals; group VI, cerulein + mesna, was treated with mesna at a dose of (100 mg/kg, i.p.) 15 min before each cerulein injection.

RESULTS

Animals with acute pancreatitis showed elevated serum amylase and lipase levels. Biochemical parameters showed increased pancreatic tumor necrosis factors-α (TNF-α) and interleukin-1β (IL-1β) levels. A disturbance in oxidative stress markers was evident by elevated pancreatic lipid peroxides (TBARS) and decline in pancreatic antioxidants' concentrations including reduced glutathione (GSH); superoxide dismutase (SOD); and glutathione peroxidase (GSH-Px). Histological examination confirmed pancreatic injury. Pre-treatment with mesna was able to abolish the changes in pancreatic enzymes, oxidative stress markers (TBARS, SOD, GSH and GSH-Px), pancreatic inflammatory markers (TNF-α, IL-1β) as well as histological changes.

CONCLUSIONS

Mesna mitigates AP by alleviating pancreatic oxidative stress damage and inhibiting inflammation.

Meta-analysis reveals an association between acute pancreatitis and the risk of pancreatic cancer

BACKGROUND

Chronic pancreatitis is associated with pancreatic cancer (PC), although the relationship between acute pancreatitis (AP) and the risk of PC remains unclear due to inconsistent and contradictory results.

AIM

To conduct a meta-analysis of retrospective and prospective studies to explore the association between AP and PC risk.

METHODS

We first searched original articles on the association of AP with PC using PubMed, Web of Science, Cochrane, and EMBASE databases. Then we calculated the combined overall effect estimates (EEs) between AP and PC risk at a 95% confidence interval (CI) deploying a random-effects model, and assessed heterogeneity using the I 2 test. The combined relative risk with 95%CI was performed to examine the relationship between AP and PC. Publication bias and subgroup analyses were also conducted. Furthermore, we performed sensitivity analysis to explain this heterogeneity.

RESULTS

Eleven studies were eligible for inclusion standards in this meta-analysis, resulting in pooled EEs of 2.07 (95%CI: 1.36-2.78) for AP and PC risk. Additionally, five prospective cohort studies reported 103961 patients in the AP group, relative to 1442158 subjects in the control group, with a pooled relative risk of 7.81 (95%CI: 5.00-12.19). We also performed subgroup analyses using different follow-up times and type of research methods (case-control or cohort). Results from analyses of different follow-up times revealed the following pooled effect values: 1-year lag period (EEs = 23.47, 95%CI: 3.26-43.68), 2-year lag period (EEs = 9.82, 95%CI: 3.01-16.64), 5-year lag period (EEs = 2.47, 95%CI: 1.93-3.02), 10-year lag period (EEs = 1.69, 95%CI: 1.26-2.11), and > 10-year lag period (EEs = 1.17, 95%CI: 0.78-1.57). With regards to the methods, the case-control studies recorded EEs = 3.03 (95%CI: -1.02 to 7.08), whereas cohort studies had EEs = 2.09 (95%CI: 1.22-2.97) pooled effect values.

CONCLUSION

Overall, our findings indicated an association between AP and PC risk. Based on subgroup analyses, AP is unlikely to be a causal factor for PC.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

BACKGROUND AND AIM

Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.

METHODS

This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.

RESULTS

In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.

CONCLUSION

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

When is parenteral nutrition indicated in the hospitalized, acutely ill patient?

PURPOSE OF REVIEW

The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients.

RECENT FINDINGS

Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility.

SUMMARY

Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

[Comparison of minimal invasive technologies for treatment of infected pancreatic necrosis]

AIM

the assessment of the role of minimally invasive interventional procedures in the treatment of patients with infected pancreatic necrosis and their safety, as well as comparison of the results of the most common modern minimally invasive techniques among themselves.

METHODS

The results of treatment of 310 patients are presented with infected destructive pancreatitis from 2013 to 2018 on the basis of the city clinical hospital named after I.V. Davydovsky. The patients were divided into three groups: in the first one (n=170) patients underwent puncture followed by drainage of necrotic foci under ultrasound and CT control, in the second (n=98) patients underwent sanation of foci completely by laparoscopic access, in the third (n=42) a series of retroperitoneoscopy was used for the same purpose.

RESULTS

In 114 (67.1%) cases, patients from the first group did not require further surgical intervention. The results of percutaneous drainage were successful. The average length of hospital stay in the first group was 27 days, in the second and third groups - 31 days (the ratio in the 2nd and 3rd groups was 1.03 (95% CI 0.97-1.08; p<0.05)). In the course of treatment, complications were identified in 35 (35.7%) patients in the 2nd and 17 (40.4%) patients in the 3rd group (ratio 0.88 (95% CI 0.82-0.94)). There were 22 (7.1%) deaths. The causes of death were: 1 (0.3%) of the patient had arrosive bleeding, 2 (0.7%) had duodenal fistulas, 19 (6.1%) multiple organ failure against the background of widespread retroperitoneal phlegmon.

CONCLUSION

The efficacy of treatment of infected pancreatic necrosis depends on the possibility of full drainage of the necrotic focus, regardless of approach. Minimally invasive techniques can reduce intraoperative trauma by reducing the wound surface, which contribute to develop systemic inflammatory response syndrome.

Effect of regional arterial infusion combined with early enteral nutrition on severe acute pancreatitis

Objective

To measure the therapeutic effects of regional arterial infusion (RAI) in combination with early enteral nutrition (EEN) in patients with severe acute pancreatitis (SAP).

Methods

A prospective randomized controlled study enrolled patients with SAP. They were randomly divided into a conventional treatment group that served as the control and a combination therapy group that received RAI combined with EEN. The Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) scores, the levels of serum biochemical indices, functional recovery, the incidence of complications and total effectiveness rate were evaluated.

Results

A total of 100 patients were enrolled in the study. The APACHE II scores and the concentrations of blood glucose, serum amylase, white blood cell count, C-reactive protein, tumour necrosis factor-α, interleukin (IL)-6, IL-10 and IL-17 were significantly decreased, while albumin and serum calcium and total effectiveness rate in the combination therapy group were significantly higher than in the conventional treatment group. The combination therapy group had a significantly reduced time to abdominal pain relief, time of first defaecation, hospital stay and incidence of complications compared with the conventional treatment group.

Conclusion

The combination of RAI and EEN improved clinical biochemical indices, reduced the incidence of complications and promoted early recovery in patients with SAP.

Benign pancreatic hyperenzymemia-Gullo's syndrome: focus on this clinical challenge. A monocentric retrospective study

BACKGROUND

An abnormal and chronic rise of pancreatic enzymes in the blood is most often due to pancreatic diseases, primarily inflammatory or neoplastic, or to numerous extra-pancreatic pathologies. Benign chronic pancreatic hyperenzymemia was described for the first time - as a separate nosological entity - in 1996 by Lucio Gullo et al. They demonstrated the existence of a benign chronic pancreatic hyperenzymemia in asymptomatic subjects and without clinical implications; however, a follow-up of at least 1-2 years is necessary during which no specific symptomatology or morpho-functional impairment of the pancreas should occur, also evaluated through the aid of instrumental diagnostic investigations such as ultrasonography (US), computed tomography (CT) or magnetic resonance cholangio pancreatography (MRCP).

METHODS

This study was performed with the analysis of a group of 43 subjects arrived at the observation of the Gastroenterology Team of Policlinico Hospital G. Rodolico in Catania-Italy which presented a chronic pancreatic hyperenzymemia, in order to establish the actual benignity of this condition over time.

RESULTS

During the follow-up, pancreatic alterations and hyperenzymemia were found in 10 patients, while hyperenzymemia was not associated with pancreatic modification in 33 patients.

CONCLUSIONS

Because of this enzymatic elevation - often conspicuous and lasting - the patient is often particularly anxious. For the same reason, the patient frequently undergoes very expensive laboratory and instrumental diagnostic methods. Good knowledge of the syndrome makes it possible to manage the event more rationally, also to reduce management costs to a minimum.

Exploring metabolic biomarkers and regulation pathways of acute pancreatitis using ultra-performance liquid chromatography combined with a mass spectrometry-based metabolomics strategy

Acute pancreatitis (AP), as a common kind of pancreas-based inflammatory disease, is accompanied by a serious and abnormal metabolism. However, the specific metabolic process of AP is still unclear. Novel and effective drugs against acute pancreatitis are urgently required. To explore the metabolic biomarkers and regulation pathways of acute pancreatitis, ultra-performance liquid chromatography (UPLC) combined with a mass spectrometry (MS)-based metabolomics strategy was used. Sixteen male adult Sprague-Dawley rats were divided into two groups: a sham operation group (SO) and an AP model group. The AP animal model was induced via the retrograde ductal infusion of 3.5% sodium taurocholate, and rats in the SO group were infused with 0.9% saline. After serum sample collection and sacrifice, a metabolomics strategy based on UPLC-MS was used to detect serum metabolites and metabolic pathways by comparing the SO and AP model groups through full-scan analysis. A total of 19 metabolites were detected in the serum for highlighting the differences between the two groups: l-arabitol, citric acid, isocitric acid, l-phenylalanine, l-tyrosine, dihydroxyacetone, l-valine, succinic acid, 3-hydroxybutyric acid, uric acid, acetylglycine, palmitic amide, homocysteine, d-glutamine, l-arginine, arachidonic acid, N-acetylserotonin, (R)-3-hydroxy-hexadecanoic acid, and d-mannose. Six crucial metabolic pathways, phenylalanine, tyrosine and tryptophan biosynthesis, arachidonic acid metabolism, glyoxylate and dicarboxylate metabolism and the citrate cycle, were involved; these have potential to become novel targets for the treatment of AP. The ingenuity pathway analysis (IPA) platform is used to gain insights into the metabolic targets in the system, referring to development disorders, cell-to-cell signaling and interactions, cellular assembly and organization, cell compromise, cell growth and proliferation, carbohydrate metabolism and others. It is suggested that UPLC-MS-based metabolomics is capable of accurately depicting the pathological mechanisms of acute pancreatitis, which can drive new drug development.

Acute pancreatitis (AP), as a common kind of pancreas-based inflammatory disease, is accompanied by a serious and abnormal metabolism.

Effect of enteral nutrition suspension on immune function in severe acute pancreatitis patients with intestinal bacterial translocation

AIM

To observe the effect of enteral nutrition suspension (TPF-DM) on the immune function of acute severe pancreatitis patients with intestinal flora translocation.

METHODS

One hundred and ten acute severe pancreatitis patients with intestinal flora translocation treated at Jiuli Songyuan District People's Liberation Army No.117 Hospital were randomly divided into either a control group or a TPF-DM group (n = 55 each). The control group was treated with conventional therapy, while the TPF-DM group were treated with TPF-DM. The levels of inflammatory indexes [white blood cell (WBC) and C-reactive protein (CRP)], biochemical indicators [albumin (ALB), amylase (AMY), and endothelin (ET)], and immune markers (IgG, IgM, and IgA) were recorded at admission, 7 and 14 d after treatment. Time to abdominal pain disappearance, hospitalization time, hospitalization costs, and mortality rate were also compared in the two groups.

RESULTS

At admission, there was no significant difference in the levels of WBC, CRP, ALB, AMY, ET, IgG, IgM, or IgA between the two groups (P > 0.05). At 7 d and 14 d after treatment, the WBC and CRP levels of the two groups showed a decreasing trend (P < 0.05). The WBC and CRP levels at 7 and 14 d after treatment were significantly lower in the TPF-DM group than in the control group (P < 0.05). At 7 d and 14 d after treatment, ALB showed a decreasing trend in both groups, and the AMY and ET levels showed a trend of increasing (P < 0.05). The ALB levels in the TPF-DM group were significantly higher than those in the control group at 7 d and 14 d after treatment, and the levels of AMY and ET were significantly lower than those in the control group (P < 0.05). There was no significant difference in the time to disappearance of abdominal pain, hospital stay, hospitalization costs, or mortality between the two groups (P > 0.05). At 7 d and 14 d after treatment, the levels of IgG, IgM, and IgA in both groups showed a trend of increase (P < 0.05), and the levels of IgG, IgM, and IgA at 7 and 14 d after treatment in the TPF-DM group were significantly higher than those in the control group (P < 0.05).

CONCLUSION

TPF-DM can effectively treat severe acute pancreatitis patients with intestinal bacterial translocation by improving their inflammatory status and immune function.