Treatment of acute pancreatitis: focus on medical care

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

WITHDRAWN: Stilamin inhibits intestinal and pancreatic injury in rats with severe acute pancreatitis by down-regulating LCN2 expression

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Early-phase peritoneal drainage and lavage in a rat model of severe acute pancreatitis

PURPOSE

To evaluate the effects of early-phase drainage on the survival rates and pancreatic pathological changes associated with severe acute pancreatitis (SAP) in a rat model.

METHODS

Sprague-Dawley rats were divided into the following groups: SAP model (control), early drainage and delayed drainage. The 24-h survival rates were compared among the groups. In addition, the serum and ascites concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10 and tumor necrosis factor (TNF)-α were measured, and pancreatic pathological changes were observed.

RESULTS

The survival rate significantly improved in the early drainage group. Compared with that observed in the control group, the serum TNF-α and IL-8 concentrations in the early drainage group decreased, while the serum IL-10 levels increased, and the ascites concentrations of IL-1β, IL-6, IL-8 and TNF-α decreased, while that of IL-10 increased significantly. In the delayed drainage group, only the ascites concentrations of TNF-α decreased. Meanwhile, the pancreatic pathological changes at 3, 6 and 24 h worsened in the early drainage group; however, the pancreatic lesions in the early drainage group were less mild than those seen in the control group.

CONCLUSIONS

Rebalancing the cytokine levels in ascites after early drainage may be a key factor for enhancing the survival rate in rats.

Intraductal infusion of taurocholate followed by distal common bile duct ligation leads to a severe necrotic model of pancreatitis in mice

OBJECTIVE

The most common etiology of acute pancreatitis results from the impaction of gallstones or sludge in the distal common bile duct (CBD). The result is pancreatic duct obstruction, diversion of bile into the pancreas, or cholestasis. In the current study, we examined whether combining both aspects, that is, infusion of the bile acid taurocholate (TC) followed by bile duct ligation (BDL), could yield a more severe form of pancreatitis that mimics biliary pancreatitis.

METHODS

In mice, after laparotomy, the CBD was infused with either normal saline (NS) or TC. Subsequently, the CBD was ligated at the ampulla.

RESULTS

Mice receiving TC infusion followed by BDL (TC + BDL) had higher mortality compared with animals receiving intraductal NS with BDL (NS + BDL). The TC + BDL arm developed more severe and diffuse pancreatic necrosis. In addition, serum amylase, IL-6, and bilirubin were significantly higher. However, pancreatic edema as well as lung and liver injury were unchanged between TC + BDL and NS + BDL.

CONCLUSIONS

In summary, the combination of bile infusion into the pancreas followed by BDL causes a more severe, necrotizing pancreatitis. We believe that this novel model of pancreatitis is useful because it can be used in transgenic mice and recapitulates several aspects of biliary pancreatitis.

Effect of glutamine on disease course in severe pancreatitis patients

AIM: To assess the influence of different parenteral nutrition (PN) regimens on the course of disease in severe acute pancreatitis (SAP) patients.

METHODS: Clinical data for 50 SAP patients treated at our hospital from January 2010 to June 2013 were retrospectively analyzed. The patients were randomly divided into either a study group (n = 25) or a control group (n = 25). Both groups underwent conventional PN therapy for one week. The study group was additionally given glutamine. The levels of amylase in urine and blood, liver function, renal function, routine blood parameters, serum complement, APACHE Ⅱ score, Balthazar CT score, total hospital stay, ICU stay, mechanical ventilation time, time to recovery of intestinal function and the incidence of complications were compared between the two groups.

RESULTS: After treatment, the levels of amylase in urine and blood and renal function showed a declining trend, and there were no statistically significant differences between the two groups (P > 0.05). Alanine aminotransferase (46.3 U/L ± 30.1 U/L vs 25.1 U/L ± 21.3 U/L), aspartase aminotransferase (31.0 U/L ± 15.3 U/L vs 20.5 U/L ± 11.7 U/L), white blood cell count (14.8 × 10⁹/L ± 4.3 × 10⁹/L vs 8.7 × 10⁹/L ± 2.1×10⁹/L) and C-reactive protein (39.8 mg/L ± 6.5 mg/L vs 30.2 mg/L ± 6.3 mg/L) were significantly higher in the control group than in the study group (P < 0.05). APACHE Ⅱ score and Balthazar CT score had no significant differences between the two groups (P > 0.05). The levels of IgA (2.4 g/L ± 0.2 g/L vs 1.7 g/L ± 0.2 g/L), IgG (9.8 g/L ± 1.2 g/L vs 8.7 g/L ± 1.0 g/L) and IgM (1.2 g/L ± 0.9 g/L vs 0.7 g/L ± 0.8 g/L) were significantly higher in the study group (P < 0.05). Total hospital stay (32.3 d ± 6.2 d vs 20.6 d ± 4.5 d), ICU stay (13.9 d ± 3.1 d vs 10.2 d ± 2.5 d), mechanical ventilation time (8.4 d ± 2.1 d vs 5.2 d ± 1.3 d) and the time to recovery of intestinal function (4.4 d ± 1.2 d vs 3.6 d ± 1.0 d) were all significantly higher in the control group (P < 0.05).

CONCLUSION: Gln containing PN regimen could significantly shorten hospital stay and mechanical ventilation time, reduce the risk of infection and other complications, and improve prognosis in SAP patients.

Acute pancreatitis

PURPOSE OF REVIEW

To review the changing insights in the pathophysiology and management of acute pancreatitis.

RECENT FINDINGS

The outdated 1992 Atlanta classification has been replaced by two new classifications, both of which acknowledge the role of organ dysfunction in determining the outcome of acute pancreatitis, and both of which have introduced a new category of 'moderate' pancreatitis. The new classifications will allow fewer patients to be classified as severe, which better reflects the risk of dying of the disease. Intra-abdominal hypertension has emerged as a relevant issue, and strategies to lower intra-abdominal pressure may often be required. Antibiotic prophylaxis has been discontinued for some time, but aggressive fluid resuscitation is also being questioned, and the role of surgery is further reduced as percutaneous drainage of collections has shown to reduce the need for more surgical interventions. If needed, surgery should be as conservative as possible, with minimally invasive strategies preferable. Newer techniques such as endoscopic transgastric drainage are being developed, but their exact role has yet to be defined.

SUMMARY

Management of severe acute pancreatitis is changing fundamentally. 'Less is more' is the new paradigm in acute pancreatitis - less antibiotics, less fluids, less surgery, which should eventually lead to less morbidity and mortality.

Severe acute pancreatitis: advances and insights in assessment of severity and management

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Admission visfatin levels predict pancreatic and peripancreatic necrosis in acute pancreatitis and correlate with clinical severity

OBJECTIVES

Adipocytes of peripancreatic and intrapancreatic adipose tissue secret adipocytokines such as leptin, adiponectin, and resistin. For resistin, a role as an early predictor of peripancreatic necrosis and clinical severity in acute pancreatitis has been reported. It was the aim of this study to investigate whether the adipocytokine visfatin is able to serve as an early marker predicting peripancreatic necrosis and clinical severity.

METHODS

A total of 50 patients (20 females and 30 males) with acute pancreatitis were included in this noninterventional, prospective, and monocentric cohort study on diagnostic accuracy. Clinical severity was classified by the Ranson score and APACHE-II (Acute Physiology and Chronic Health Evaluation II) score. Pancreatic and peripancreatic necrosis were quantified by the computed tomography-based Balthazar score, the Schroeder score, and the pancreatic necrosis score. Visfatin was measured at admission and daily for 10 days by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Visfatin values were significantly and positively correlated with clinical severity (APACHE-II score and Ranson score) and with clinical end points such as death and need for interventions. Admission visfatin levels were significantly elevated in patients with higher pancreatic and extrapancreatic necrosis scores. It was shown by receiver operator characteristics that admission visfatin concentration provides a positive predictive value of 93.3% in predicting the extent of peripancreatic necrosis (area under the curve (AUC): 0.89, P<0.001, sensitivity: 93.3%, specificity: 81.8%, likelihood ratio: 5.1, post-test probability: 93%) by using a cutoff value of 1.8 ng/ml.

CONCLUSIONS

Admission visfatin concentration serves as an early predictive marker of peripancreatic necrosis and clinical severity in acute pancreatitis. Visfatin may have potential for clinical use as a new and diagnostic serum marker.

Pancreatitis: understanding the disease and implications for care

Pancreatitis, or inflammation of the pancreas, has a variety of etiologies. Severity of the disease can range from its mildest form, which resolves quickly with few complications, to its most severe form, necrotizing pancreatitis, which is associated with an increased risk for developing multiple system organ failure and mortality. Treatment of pancreatitis aims to eliminate the etiologic factors for the disease while managing its complications and preventing further disease progression. Patients with mild forms of pancreatitis may improve with symptom management, whereas those with more severe disease will need significant supportive interventions. Most patients are managed medically. Surgery may be indicated for severe pancreatitis. It is important to understand the disease process and its impact on other organ systems when caring for these patients. Accurate assessment of changes in the patient's condition can lead to interventions that can limit complications and reduce the risk of mortality. This article reviews the pathophysiology of pancreatitis, its diagnosis and treatment, associated complications and their management, and essential nursing assessment and interventions.