Incidence and mortality of acute and chronic pancreatitis in the Netherlands: A nationwide record-linked cohort study for the years 1995-2005

Global, regional, and national burden of pancreatitis in children and adolescents

BACKGROUND

Pancreatitis poses a growing public health concern among children and adolescents, yet comprehensive data on its prevalence, incidence, mortality, and disability-adjusted life years (DALYs) remain scarce. This study aims to analyze global, regional, and national trends in pancreatitis burden over the past 3 decades.

METHODS

Using data from the Global Burden of Disease (GBD) 2019 database spanning 1990-2019, we assessed pancreatitis prevalence, incidence, mortality, and DALYs, reporting on numbers, rates, age-standardized prevalence rate (ASPR), age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), age-standardized DALYs rate (ASDR), and average annual percentage changes (AAPCs). Trends were analyzed by age, sex, region, and socio-demographic index (SDI) using jointpoint analysis and predictive modeling.

RESULTS

Globally, pancreatitis prevalence and incidence rates have increased (AAPC prevalence = 0.13, 95% CI: 0.11-0.16; AAPC incidence = 0.30, 95% CI: 0.28-0.32), while mortality and DALYs rates have decreased (AAPC mortality = -1.30, 95% CI: -1.53, -1.07; AAPC DALYs = -1.21, 95% CI: -1.41, -1.01). Both genders showed similar trends. Children under 5 and adolescents 15-19 had higher mortality and DALYs rates. Low SDI regions experienced the greatest increase in ASIR. Eastern Europe exhibited high and rising ASIR, ASMR, and ASDR. Projections indicate continued rise in prevalence with declining mortality and DALYs.

CONCLUSION

Pancreatitis burden in children and adolescents has surged globally, especially in lower SDI regions. These findings underscore the urgent need for targeted interventions and healthcare resources in affected areas.

Patient and Family Input to Determine Experiences and Research Interests in Pediatric Pancreatitis: An INSPPIRE-2 Study

OBJECTIVE

The aim of this study was to determine patient-reported burdensome experiences and research interests in children with acute recurrent pancreatitis or chronic pancreatitis and their families.

MATERIALS AND METHODS

Children with pancreatitis and their families completed a web-based survey. Subject prioritized rankings of symptoms or quality of life issues and topics for future research were assessed. Data are presented as family and children scores.

RESULTS

Among 80 participants, 18 were children with pancreatitis and 62 were family members. Top 5 ranked symptoms or quality of life issues were as follows: 1) pain, 2) fatigue, 3) missing school, 4) upset stomach, and 5) not knowing when an attack will occur. Top 5 ranked future research topics were as follows: 1) how to prevent a pancreatitis attack, 2) how pancreatitis affects other parts of the body, 3) ways to treat or handle pain, 4) what is the cause of pancreatitis, and 5) teach doctors about pancreatitis.

CONCLUSIONS

This study highlights the importance of patient and family input in caring for children with pancreatitis. The most bothersome symptoms were pain, fatigue, and upset stomach. Children with pancreatitis and families would like future research to primarily focus on prevention of pancreatitis attacks, pain therapy, and complications of pancreatitis.

Computed tomography-based body composition indicative of diabetes after hypertriglyceridemic acute pancreatitis

BACKGROUND

Post‑acute pancreatitis prediabetes/diabetes mellitus (PPDM‑A) is one of the common sequelae of acute pancreatitis (AP). The aim of our study was to build a machine learning (ML)-based prediction model for PPDM-A in hypertriglyceridemic acute pancreatitis (HTGP).

METHODS

We retrospectively enrolled 165 patients for our study. Demographic and laboratory data and body composition were collected. Multivariate logistic regression was applied to select features for ML. Support vector machine (SVM), linear discriminant analysis (LDA), and logistic regression (LR) were used to develop prediction models for PPDM-A.

RESULTS

65 patients were diagnosed with PPDM-A, and 100 patients were diagnosed with non-PPDM-A. Of the 84 body composition-related parameters, 15 were significant in discriminating between the PPDM-A and non-PPDM-A groups. Using clinical indicators and body composition parameters to develop ML models, we found that the SVM model presented the best predictive ability, obtaining the best AUC=0.796 in the training cohort, and the LDA and LR model showing an AUC of 0.783 and 0.745, respectively.

CONCLUSIONS

The association between body composition and PPDM-A provides insight into the potential pathogenesis of PPDM-A. Our model is feasible for reliably predicting PPDM-A in the early stages of AP and enables early intervention in patients with potential PPDM-A.

Endoscopic Retrograde Cholangio-Pancreatography and Endoscopic Ultrasound in the Management of Paediatric Acute Recurrent Pancreatitis and Chronic Pancreatitis

Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort.

Diagnosis and Management of Acute Pancreatitis

Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.

Chronic Pancreatitis in a Large Developing Country: Temporal Trends of Over 64,000 Hospitalizations from 2009 to 2019

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a progressive inflammatory disorder associated with marked morbidity and mortality and frequently requires hospitalization. This study aimed to investigate the time trends and geographical distribution of hospital admissions, the lethality rate of CP across Brazil, and the potential relationship with social indicators and associated risk factors.

METHODS

Data were retrospectively obtained from the Brazilian Public Health System Registry between January 2009 and December 2019. The prevalence and lethality rates of CP per 100,000 inhabitants in each municipality were estimated from hospitalizations to in-hospital deaths and classified by age, sex, and demographic features.

RESULTS

During the study period, 64,609 admissions were retrieved, and most of the patients were males (63.54%). Hospitalization decreased by nearly half (-54.68%) in both sexes. CP rates in males were higher in all age groups. The greatest reduction in admissions (- 64%) was also noted in patients ≥ 70y. CP In-hospital lethality remained stable (5-6%) and similar for males and females. Patients ≥ 70y showed the highest lethality. The greatest increase in CP lethality rates (+ 10%) was observed in municipalities integrated into metropolises, which was mainly driven by small-sized municipalities (+ 124%).

CONCLUSIONS

CP hospitalizations decrease in both urban and rural areas, particularly in the North, Northeast, and Central-West regions, and in those above 70 years of age, but are not correlated with lethality rates in the South. This suggests ongoing changes in the environmental and socioeconomic factors in Brazil.

Quantitative CT features on admission combined with laboratory biomarkers for predicting severe acute pancreatitis

AIM

To assess the association of quantitative computed tomography (CT) features on admission with acute pancreatitis (AP) severity, and to explore the performance of combined CT and laboratory markers for predicting severe AP (SAP).

MATERIALS AND METHODS

Data from 208 AP patients were reviewed retrospectively. Pancreas volume, the area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were calculated based on CT images on admission. Laboratory biomarkers within 24 h of admission were collected. Interobserver agreement for CT measurements was measured by calculating interclass correlation coefficient (ICC). The associations of quantitative CT features with AP severity were evaluated. Predictive models for SAP were constructed based on CT and laboratory markers. Performances of single marker and the models were evaluated using receiver operating characteristic (ROC) curve and area under the ROC curve (AUC).

RESULTS

Pancreas volume, area of extrapancreatic inflammation, extrapancreatic fluid collection volume, and number were significantly different between severe and non-severe AP groups. In predicting SAP, the AUCs of quantitative CT indicators ranged from 0.72 to 0.79; the AUCs of laboratory biomarkers were between 0.53 and 0.66. The combined model of area of extrapancreatic inflammation, serum calcium, and haematocrit yielded an AUC of 0.84, significantly higher than that of the laboratory model, single CT, or laboratory marker. Interobserver agreements for quantitative CT indicators were excellent, with ICC ranging from 0.91 to 0.98.

CONCLUSION

Quantitative CT features on admission were significantly associated with AP severity; the combination of extrapancreatic inflammation area, serum calcium, and haematocrit could be taken as a new method for predicting SAP.

Surgical and Endoscopic Intervention for Chronic Pancreatitis in Children: The Kings College Hospital Experience

Paediatric chronic pancreatitis (CP) is a rare and debilitating pathology that often requires invasive diagnostics and therapeutic interventions either to address a primary cause such as a pancreaticobiliary malunion or to deal with secondary complications such as chronic pain. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are two endoscopic modalities that have an established diagnostic role in paediatric CP, and their therapeutic utilisation is increasing in popularity. Surgical decompression of the obstructed and dilated pancreatic duct plays a role in alleviating pancreatic duct hypertension, a common association in CP. Surgery equally has a role in certain anatomical abnormalities of the pancreaticobiliary draining system, or occasionally in some CP complications such as drainage of a symptomatic pancreatic pseudocyst.

Genetics and Genomics of Chronic Pancreatitis with a Focus on Disease Biology and Molecular Pathogenesis

Chronic pancreatitis is a long-term fibroinflammatory condition of the pancreas with varying incidences across countries. The recent increase in its occurrence implies the involvement of genetic, hereditary, and unconventional risk factors. However, there is a lack of updated literature on recent advances in genetic polymorphisms of chronic pancreatitis. Therefore, this review aims to present recent findings on the genetic implications of chronic pancreatitis based on individual gene mechanisms and to discuss epigenetics and epistasis involved in the disease. Four mechanisms have been implicated in the pathogenesis of chronic pancreatitis, including premature activation of proteases, endoplasmic reticulum stress, ductal pathway dysfunction, and inflammatory pathway dysfunction. These mechanisms involve genes such as PRSS1, PRSS2, SPINK, CEL, PNLIP, PNLIPRP2, CFTR, CaSR, CLDN2, Alpha 1 antitrypsin, and GGT1 . Studying genetic polymorphisms on the basis of altered genes and their products may aid clinicians in identifying predispositions in patients with and without common risk factors. Further research may also identify associations between genetic predispositions and disease staging or prognosis, leading to personalized treatment protocols and precision medicine.

Clinical and Genetic Description of Hereditary Chronic Pancreatitis in Pakistani Children

BACKGROUND/AIMS

The purpose of this study was to identify the spectrum and frequency of pathogenic variants as well as the clinical and genetic insight of hereditary chronic pancreatitis in Pakistani children.

MATERIALS AND METHODS

The deoxyribonucleic acid of affected probands of 44 unrelated Pakistani families, having hereditary chronic pancreatitis-affected children, were subjected to massive parallel sequencing for candidate reported genes (SPINK1, PRSS1, CFTR, CPA1, CTRC, CBS, AGL, PHKB, and LPL). Data were analyzed using different bioinformatics tools for the variants and in-silico analysis. All the identified variants were validated by direct sequencing of the targeted exons in the probands and their parents.

RESULTS

There were 50 patients included in this study with confirmed hereditary chronic pancreatitis. Nine known mutations in SPINK1, PRSS1, CFTR, CTRC, CBS, and AGL genes, and 10 novel variants in LPL, CFTR, CTR, and PHKB genes were identified. The identified variants were found in heterozygous, compound heterozygous, and trans-heterozygous forms, with rare allele frequency in the normal population. The novel variants were [c.378C>T(p.Lys126Asn) and c.719G>A(p.Arg240Gln) in CTRC, c.586-3C>A and c.763A>G(p.Arg255Gly) in CPA1, c.1160_1161insT(p.Lys387Asnfs*26), c.784C>T(p.Gln262*), c.1139+1G>A, c.175G>A(p.Gly59Arg) in LPL, c.388C>G(p.leu130val) in CFTR, and c.2327G>A(p.Arg776His in PHKB)]. The phenotypic characteristics were variable and correlated with the relevant variant.

CONCLUSIONS

The genetic composition plays a significant role in the predisposition of hereditary chronic pancreatitis. The clinical presentation varies with the genetic determinant involved. This information would help in building up a diagnostic algorithm for our population that can be used for genetic screening services in affected cohorts.

Acute peripancreatic fluid collection in acute pancreatitis: Incidence, outcome, and association with inflammatory markers

Background

The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC.

Methods

In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours.

Results

Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates.

Conclusions

While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

Age-period-cohort analysis of pancreatitis epidemiological trends from 1990 to 2019 and forecasts for 2044: a systematic analysis from the Global Burden of Disease Study 2019

Objective

Pancreatitis poses a serious medical problem worldwide. This study aims to explore the epidemiological trends of pancreatitis from 1990 to 2019, analyze the association between disease burden and age, period and birth cohort, and subsequently present a forecast of pancreatitis incidence and deaths.

Methods

Epidemiologic data were gathered from the Global Health Data Exchange query tool. Joinpoint regression model was used to calculate the average annual percentage changes (AAPCs). Age-period-cohort analysis was utilized to estimate the independent effects of age, period and birth cohort. We also predicted the global epidemiological trends to 2044.

Results

Globally, the incident cases and deaths of pancreatitis increased 1.63-and 1.65-fold from 1990 to 2019, respectively. Joinpoint regression analysis showed that the age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) decreased over the past three decades. The age effect indicates that older people have higher age-specific incidence and death rates. The period effect on incidence and deaths showed downward trends from 1990 to 2019. The cohort effect demonstrated that incidence and death risk peaked in the earlier birth cohort and were lower in the latest birth cohort. Incident cases and deaths of pancreatitis may significantly increase in the next 25 years. The ASIRs were predicted to slightly increase, while the ASDRs were predicted to decrease.

Conclusion

Epidemiologic patterns and trends of pancreatitis across age, period and birth cohort may provide novel insight into public health. Limitations of alcohol use and prevention strategies for pancreatitis are necessary to reduce future burden.

Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020

BACKGROUND AND OBJECTIVE

Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.

METHODS

We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.

RESULTS

12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.

CONCLUSIONS

In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.

Elevated hypertriglyceridemia and decreased gallstones in the etiological composition ratio of acute pancreatitis as affected by seasons and festivals: A two-center real-world study from China

Objective

The purpose of this study was to observe the annual variation in the etiology of acute pancreatitis (AP) and its relationship with seasons and festivals.

Methods

From 2011 to 2017, 5146 adult patients with AP were studied, including 4110 patients from the First Affiliated Hospital of Nanchang University (South center) and 1036 patients from the First Affiliated Hospital of Harbin Medical University (North center). We analyzed the overall annual variation in the etiology of AP and then compared the differences in etiology between the two regions, as well as the effects of seasons and festivals on the etiology of AP.

Results

Gallstones, hypertriglyceridemia (HTG) and alcohol were the top three etiologies of AP. Gallstone AP showed a downward trend (P<0.001), and HTG-AP and alcohol AP showed an upward trend (both P<0.01). Among the etiologies of AP, gallstones and HTG were affected by seasons and festivals. The composition ratio of HTG-AP increased, while gallstone AP decreased in winter and in months with long holidays (all P<0.01). The composition ratio of gallstone AP in the south center was higher than that in the north center (59.5% vs. 49%), especially in summer (62.9% vs. 44.0%) and autumn (61.5% vs. 45.7%, all P<0.001).

Conclusions

The composition ratio of HTG-AP increased while gallstone AP decreased in the past 7 years, and they were affected by seasons and festivals.

Trends in Early and Late Mortality in Patients With Severe Acute Pancreatitis Admitted to ICUs: A Nationwide Cohort Study

OBJECTIVES

To investigate national mortality trends over a 12-year period for patients with severe acute pancreatitis (SAP) admitted to Dutch ICUs. Additionally, an assessment of outcome in SAP was undertaken to differentiate between early (< 14 d of ICU admission) and late (> 14 d of ICU admission) mortality.

DESIGN

Data from the Dutch National Intensive Care Evaluation and health insurance companies' databases were extracted. Outcomes included 14-day, ICU, hospital, and 1-year mortality. Mortality before and after 2010 was compared using mixed logistic regression and mixed Cox proportional-hazards models. Sensitivity analyses, excluding early mortality, were performed to assess trends in late mortality.

SETTING

Not applicable.

PATIENTS

Consecutive adult patients with SAP admitted to all 81 Dutch ICUs between 2007 and 2018.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Among 4,160 patients treated in 81 ICUs, 14-day mortality was 17%, ICU mortality 17%, hospital mortality 23%, and 1-year mortality 33%. After 2010 in-hospital mortality adjusted for age, sex, modified Marshall, and Acute Physiology and Chronic Health Evaluation III scores were lower (odds ratio [OR], 0.76; 95% CI, 0.61-0.94) than before 2010. There was no change in ICU and 1-year mortality. Sensitivity analyses excluding patients with early mortality demonstrated a decreased ICU mortality (OR, 0.45; 95% CI, 0.32-0.64), decreased in-hospital (OR, 0.48; 95% CI, 0.36-0.63), and decreased 1-year mortality (hazard ratio, 0.81; 95% CI, 0.68-0.96) after 2010 compared with 2007-2010.

CONCLUSIONS

Over the 12-year period examined, mortality in patients with SAP admitted to Dutch ICUs did not change, although after 2010 late mortality decreased. Novel therapies should focus on preventing early mortality in SAP.

The predictive value of procalcitonin combined with C-reactive protein and D dimer in moderately severe and severe acute pancreatitis

OBJECTIVE

The objective of this study is to investigate the predictive value of a parametric model constructed by using procalcitonin, C-reactive protein (CRP) and D dimer within 48 h after admission in moderately severe and severe acute pancreatitis.

METHODS

A total of 238 patients were enrolled, of which 170 patients were moderately severe and severe acute pancreatitis (MSAP+SAP). The concentrations of procalcitonin, CRP and D dimer within 48 h after admission were obtained. The predictive value of the parametric model, modified computed tomography severity index (MCTSI), bedside index for severity in acute pancreatitis (BISAP), Ranson score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, modified Marshall score and systemic inflammatory response syndrome (SIRS) score of all patients was calculated and compared.

RESULTS

The area under receiver operator characteristic curve, sensitivity, specificity, Youden index and critical value of the parametric model for predicting MSAP+SAP were 0.853 (95% CI, 0.804-0.903), 84.71%, 70.59%, 55.30% and 0.2833, respectively. The sensitivity of the parametric model was higher than that of MCTSI (84.00%), Ranson score (73.53%), BISAP (56.47%), APACHE II score (27.65%), modified Marshall score (17.06%) and SIRS score (78.24%); the specificity of it were higher than that of MCTSI (52.94%) and Ranson score (67.65%), but lower than BISAP (73.53%), APACHE II score (76.47%), modified Marshall score (100%)and SIRS score (100.00%).

CONCLUSION

The parametric model constructed by using procalcitonin 48 h, CRP 48 h and D dimer 48 h can be regarded as an evaluation model for predicting moderately severe and severe acute pancreatitis.

The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee

OBJECTIVES

Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children.

METHODS

The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP.

RESULTS

Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation.

CONCLUSIONS

The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.

The Epidemiology and Burden of Childhood Chronic Pancreatitis in South Australia

OBJECTIVE

To assess longitudinal, population-based data on the prevalence and impact of chronic pancreatitis in children.

STUDY DESIGN

Administrative data linkage was used to ascertain an index cohort consisting of all individuals who had an initial diagnosis of chronic pancreatitis before age 19 years in the South Australian public hospital system between June 2000 and June 2019. Age- and sex-matched controls were drawn from the general population of South Australia, children with type 1 diabetes, and children with type 2 diabetes. Main outcomes and measures included hospital visits, days in hospital, emergency department (ED) visits, intensive care unit (ICU) admissions, education comparators, and incidence and prevalence estimates.

RESULTS

A total of 73 incident cases were identified. The crude prevalence and incidence of pediatric chronic pancreatitis were estimated at 6.8/100 000 and 0.98/100 000 per year, respectively. Of the index cohort, 24 cases (32.8%) of pediatric chronic pancreatitis were identified as occurring in children of Aboriginal and/or Torres Strait Islander descent. Compared with matched general population controls, children with chronic pancreatitis averaged 11-fold more hospital visits, 5-fold more ED visits, and 9-fold more ICU admissions; spent 10-fold more days in the hospital; and had a 2-fold higher rate of absence from school (P < .001 for all). Similarly, children with chronic pancreatitis used substantially more health resources than children with type 1 or 2 diabetes.

CONCLUSIONS

Pediatric patients with chronic pancreatitis consume a high volume of public health services and are significantly impacted in their ability to engage in education.

Safety and efficacy of a novel resection system for direct endoscopic necrosectomy of walled-off pancreas necrosis: a prospective, international, multicenter trial

BACKGROUND AND AIMS

Direct endoscopic necrosectomy (DEN) of walled-off pancreatic necrosis (WOPN) lacks dedicated instruments and requires repetitive and cumbersome procedures. This study evaluated the safety and efficacy of a new powered endoscopic debridement (PED) system designed to simultaneously resect and remove solid debris within WOPN.

METHODS

This was a single-arm, prospective, multicenter, international device trial conducted from November 2018 to August 2019 at 10 sites. Patients with WOPN ≥6 cm and ≤22 cm and with >30% solid debris were enrolled. The primary endpoint was safety through 21 days after the last DEN procedure. Efficacy outcomes included clearance of necrosis, procedural time, adequacy of debridement, number of procedures until resolution, hospital stay duration, and quality of life.

RESULTS

Thirty patients (mean age, 55 years; 60% men) underwent DEN with no device-related adverse events. Of 30 patients, 15 (50%) achieved complete debridement in 1 session and 20 (67%) achieved complete debridement within 2 or fewer sessions. A median of 1.5 interventions (range, 1-7) were required. Median hospital stay was 10 days (interquartile range, 22). There was an overall reduction of 91% in percent necrosis within WOPN from baseline to follow-up and 85% in collection volume. Baseline WOPN volume was positively correlated with the total number of interventions (ρ = .363, P = .049).

CONCLUSIONS

The new PED system seems to be a safe and effective treatment tool for WOPN, resulting in fewer interventions and lower hospital duration when compared with published data on using conventional instruments. Randomized controlled trials comparing the PED system with conventional DEN are needed. (Clinical trial registration number: NCT03694210.).

Predictive value of arterial blood lactic acid concentration on the risk of all-cause death within 28 days of admission in patients with severe acute pancreatitis

ObjectiveTo evaluate the ability of arterial blood lactic acid concentration to predict death within 28 days of admission of patients with severe acute pancreatitis (SAP) in the intensive care unit (ICU).MethodsClinical data of 523 SAP patients in the MIMIC-IV database were retrospectively analyzed. Patients were divided into those who survived (n=461) and those who died (n=62) within 28 days of admission. The association between lactic acid concentration and all-cause death in SAP patients was determined by Cox regression analysis, Kaplan-Meier survival analysis and subgroup analysis. The ability of lactic acid concentration to predict the risk of all-cause death in SAP patients was determined by time-dependent receiver operating curve (ROC) analysis.ResultsArterial blood lactic acid concentration was significantly higher in the 62 patients who died within 28 days than in the 461 patients who survived (P <0.05). Adjusted multivariate Cox regression analysis showed that lactic acid concentration was a significant independent predictor on all-cause mortality within 28 days of admission for SAP (hazard ratio=1.22, 95% confidence interval 1.09-1.36, P <0.001), as did time-dependent ROC analysis (area under the ROC curve=0.741). Kaplan-Meier analysis showed that the rate of all-cause mortality within 28 days of admission was significantly higher in patients with high than low lactic acid concentration (P <0.0001). Subgroup analysis showed that there was no significant interaction between lactic acid concentration and other factors with all-cause death within 28 days of admission (all P >0.05).ConclusionArterial blood lactic acid concentration is an important independent predictor of all-cause mortality within 28 days of admission of SAP patients in the ICU.

Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Acute pancreatitis is a common disease with significant associated morbidity and mortality. We performed a systematic review and meta-analysis of population-based studies to explore the changing temporal trends of acute pancreatitis incidence globally.

METHODS

We performed a systematic literature search to identify population-based studies reporting the annual incidence of acute pancreatitis. Abstracts were assessed independently to identify applicable articles for full-text review and data extraction. Joinpoint temporal trend analyses were performed to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs). The AAPCs were pooled in a meta-analysis to capture the overall and regional trends in acute pancreatitis incidence over time. Temporal data were summarized in a static map and an interactive, web-based map.

RESULTS

Forty-four studies reported the temporal incidence of acute pancreatitis (online interactive map: https://kaplan-acute-pancreatitis-ucalgary.hub.arcgis.com/). The incidence of acute pancreatitis has increased from 1961 to 2016 (AAPC, 3.07%; 95% CI, 2.30% to 3.84%; n = 34). Increasing incidence was observed in North America (AAPC, 3.67%; 95% CI, 2.76% to 4.57%; n = 4) and Europe (AAPC, 2.77%; 95% CI, 1.91% to 3.63%; n = 23). The incidence of acute pancreatitis was stable in Asia (AAPC, -0.28%; 95% CI, -5.03% to 4.47%; n = 4).

CONCLUSIONS

This meta-analysis provides a comprehensive overview of the global incidence of acute pancreatitis over the last 56 years and demonstrates a steadily rising incidence over time in most countries of the Western world. More studies are needed to better define the changing incidence of acute pancreatitis in Asia, Africa, and Latin America.

The prognostic value of fat necrosis deposits on CT imaging in acute pancreatitis

Background/aim

Investigate the prognostic value of the fat necrosis deposit (FND) pattern in acute pancreatitis.

Materials and methods

The contrast-enhanced computed tomography (CT) images of 35 necrotizing pancreatitis (NP) and 51 edematous pancreatitis (EP) cases were included in our retrospective study. Computed tomography severity index (CTSI) and Ranson scores were calculated. Images were evaluated for FND, complications (infection/ hemorrhage), walled-off necrosis (WON), and venous thrombosis (VT). We developed a new grading system called fat necrosis deposit-CTSI (FND-CTSI), which was the sum of FND and CTSI scores. The relationship between grading systems and mortality, length of hospital-intensive care unit stay, surgical and percutaneous interventions were evaluated.

Results

FND-CTSI scores were significantly higher in NP than EP (P < 0.001). FND-CTSI demonstrated a significant correlation with CTSI (r:0.91, P < 0.001) and Ranson score (r:0.24, P = 0.025). CTSI was significantly higher in only mass form amongst the FND groups (P < 0.001). There was a significant difference in WON, complications, and mortality between FND groups (P < 0.05). CTSI and FND-CTSI scores were both significantly associated with WON, VT, surgical intervention, mortality (P < 0.001), and the presence of complications (P = 0.013 and P = 0.007, respectively). FND-CTSI was also significantly associated with percutaneous intervention (P = 0.019), while CTSI was not (P > 0.05). According to ROC analysis, AUC values of FND-CTSI were higher than CTSI for the detection of WON, complications, mortality, and percutaneous intervention (P < 0.05). FND-CTSI showed a highly significant correlation with the length of hospital and intensive care unit stays (P < 0.001).

Conclusion

FND-CTSI can be used in acute pancreatitis grading and considered as a prognostic factor.

Sex Differences in the Exocrine Pancreas and Associated Diseases

Differences in pancreatic anatomy, size, and function exist in men and women. The anatomical differences could contribute to the increase in complications associated with pancreatic surgery in women. Although diagnostic criteria for pancreatitis are the same in men and women, major sex differences in etiology are reported. Alcohol and tobacco predominate in men, whereas idiopathic and obstructive etiologies predominate in women. Circulating levels of estrogens, progesterone, and androgens contribute significantly to overall health outcomes; premenopausal women have lower prevalence of cardiovascular and pancreatic diseases suggesting protective effects of estrogens, whereas androgens promote growth of normal and cancerous cells. Sex chromosomes and gonadal and nongonadal hormones together determine an individual's sex, which is distinct from gender or gender identity. Human pancreatic disease etiology, outcomes, and sex-specific mechanisms are largely unknown. In rodents of both sexes, glucocorticoids and estrogens from the adrenal glands influence pancreatic secretion and acinar cell zymogen granule numbers. Lack of corticotropin-releasing factor receptor 2 function, a G protein-coupled receptor whose expression is regulated by both estrogens and glucocorticoids, causes sex-specific changes in pancreatic histopathology, zymogen granule numbers, and endoplasmic reticulum ultrastructure changes in acute pancreatitis model. Here, we review existing literature on sex differences in the normal exocrine pancreas and mechanisms that operate at homeostasis and diseased states in both sexes. Finally, we review pregnancy-related pancreatic diseases and discuss the effects of sex differences on proposed treatments in pancreatic disease.

Hypercalcemia induced pancreatitis as a rare presentation of primary hyperparathyroidism

Acute pancreatitis (AP) is an inflammatory process of the pancreas. It is a relatively common cause of acute upper abdominal pain and is potentially associated with high morbidity and mortality. Underlying hypercalcemia as a cause of AP is very rare. We present a case of a hypercalcemia-induced acute pancreatitis with an underlying parathyroid adenoma in an 81-year-old woman with no previous symptoms of hypercalcemia. The parathyroid adenoma was semi-urgently surgically resected with normalization of calcium-levels. This case report summarizes the causes of acute pancreatitis and hypercalcemia and its management.

The Role of the Body Mass Index in the Acute Pancreatitis Evolution

The etiological factors involved in acute pancreatitis are multiple, both pancreatic and extra-pancreatic, having a predisposing or triggering role. The purpose of our study was to evaluate the role of BMI (body mass index) in the evolution of acute pancreatitis. The study was performed between January 2018-October 2020 on a lot of 110 patients diagnosed with acute pancreatitis and admitted to the 1^stSurgery Clinic and the 2^ndMedical Clinic of the Craiova Emergency County Clinical Hospital, the study was prospective. The control lot consisted of patients who were not diagnosed with acute pancreatitis (n=232).Comparing the distributions according to the body mass index of the two groups by the Chi square test, a statistically significant difference is observed (p<0.05) regarding the obese patients who are diagnosed with acute pancreatitis. Obesity patients have an increased risk of developing acute pancreatitis compared to non-obese patients.

Medical Management of Chronic Pancreatitis in Children: A Position Paper by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee

ABSTRACT

This position paper summarizes the current understanding of the medical management of chronic pancreatitis (CP) in children in light of the existing medical literature, incorporating recent advances in understanding of nutrition, pain, lifestyle considerations, and sequelae of CP. This article complements and is intended to integrate with parallel position papers on endoscopic and surgical aspects of CP in children. Concepts and controversies related to pancreatic enzyme replacement therapy (PERT), the use of antioxidants and other CP medical therapies are also reviewed. Highlights include inclusion of tools for medical decision-making for PERT, CP-related diabetes, and multimodal pain management (including an analgesia ladder). Gaps in our understanding of CP in children and avenues for further investigations are also reviewed.

The Relationship Between Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios With Hospital Stays and Mortality in the Emergency Department

Background Most acute pancreatitis scoring is made in the first 48-72 hours or later. Like many inflammatory processes, Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) can be useful in showing the severity and extent of inflammation in acute pancreatitis. Our study aimed to evaluate whether these rates affect mortality according to the NLR and PLR values ​​of patients diagnosed with acute pancreatitis by examining the blood samples taken within the first hour after admission to the emergency department rates are useful in predicting the length of stay. Methods In our retrospective study, 557 patients applied to our clinic for 4.5 years, whose amylase and lipase values ​​were higher than two times the cut-off value in blood tests and whose CT imaging was compatible with acute pancreatitis were included in the study. Results The median length of hospitalization of the patients was 4.0 (3.0-6.0) days. Gallstones were detected in 320 (57.5%) patients. Mortality of less than a year was observed in 45 (8.1%) of the study population. Eighteen of the patients (3.2%) showed the need for follow-up in the intensive care unit. A statistically significant relationship was found between mortality and variables hematocrit (HCT), red cell distribution width (RDW),c-reactive protein CRP), glucose, urea, potassium, albumin, PLR, and NLR (p <0.05). A statistically significant correlation was observed between RDW, NLR, glucose, and CRP levels in the two groups divided according to the median value of 4 days we found on hospitalization (p <0.05). According to the graphics and test results obtained by ROC analysis, the mortality status can be predicted at a statistically significant level with PLR and NLR diagnostic tests (p <0.05). Conclusion High levels of NLR, PLR, RDW, glucose, CRP, urea, potassium, low albumin and hematocrit values ​​at the first admission in the Emergency Service seem to be associated with increased 1-year mortality in acute pancreatitis.

Acute pancreatitis: 31-Year trends in incidence and mortality - A Danish population-based cohort study

BACKGROUND

Objectives: Increasing incidence rates and declining mortality rates have made acute pancreatitis a common cause of hospitalization. We aimed to examine 31-year trends in first-time hospitalization for acute pancreatitis, the subsequent short-term and long-term mortality, and the prognostic impacts of age, sex, and comorbidity.

METHODS

In this nationwide Danish population-based cohort study of 47,711 incident cases, we computed the annual sex-specific age-standardized incidence rates of acute pancreatitis for 1988-2018. Among patients with incident hospitalization for acute pancreatitis, we computed sex-specific 30-day and 31-365-day mortality rates, stratified them, and performed proportional-hazards regression to estimate mortality rate ratios adjusted for sex, age, and comorbidity, measured by Charlson Comorbidity Index categories.

RESULTS

From 1988 to 2018, the standardized incidence rate of acute pancreatitis per 100,000 person-years increased by 29% for men (28.8-37.0%) and by 148% for women (15.7-38.9%). Among patients with pancreatitis, the 30-day mortality declined from 10.0% in those diagnosed in 1988-1992 to 6.3% for those diagnosed in 2013-2017. The corresponding 31-365 day mortality increased from 5.5% to 6.0%. In comparing periods 1988-1992 and 2013-17, the adjusted 30-day mortality rate ratio was 0.36 (95% confidence interval: 0.32-0.41) and the adjusted 31-365 day mortality rate ratio was 0.64 (95% confidence interval: 0.56-0.74). Comorbidity was a strong predictor of mortality among patients with pancreatitis.

CONCLUSIONS

Over the 31 years of observations, annual rates of acute pancreatitis more than doubled among women, converging with those among men. The comorbidity burden was a strong prognostic factor for short and long-term mortality. Treatments for acute pancreatitis should focus on existing comorbidities.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of visceral adipose tissue on the incidence and severity of acute pancreatitis: A systematic review

BACKGROUND

With the rising prevalence of obesity, there is a plethora of literature discussing the relationship between obesity and acute pancreatitis (AP). Evidence has shown a possible correlation between visceral adipose tissue (VAT) and AP incidence and severity. This systematic review explores these associations.

METHODS

Eligible articles were searched and retrieved using Medline and Embase databases. Clinical studies evaluating the impact of VAT as a risk factor for AP and the association of the severity of AP and VAT were included.

RESULTS

Eleven studies, with a total of 2529 individuals were reviewed. Nine studies showed a statistically significant association between VAT and the severity of AP. Only four studies found VAT to be a risk factor for acute pancreatitis. Two studies showed VAT to be associated with an increased risk of local complications and two studies showed a correlation between VAT and mortality.

CONCLUSION

This is the first systematic review conducted to study the association between VAT and AP. The existing body of evidence demonstrates that VAT has a clinically relevant impact and is an important prognostic indicator of the severity of AP. However, it has not shown to be an independent risk factor to the risk of developing AP. The impact of VAT on the course and outcome of AP needs to be profoundly explored to confirm these findings which may fuel earlier management and better define the prognosis of patients with AP. VAT may need to be incorporated into prognostic scores of AP to improve accuracy.

Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study

INTRODUCTION

Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP.

METHODS AND ANALYSIS

PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months.

ETHICS AND DISSEMINATION

PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Netherlands Trial Registry (NL7066). Prospectively registered.

The diagnostic value of serum C-reactive protein, procalcitonin, interleukin-6 and lactate dehydrogenase in patients with severe acute pancreatitis

OBJECTIVE

Acute pancreatitis (AP) is an inflammatory disease with rapid progression. In severe cases, it can cause systemic inflammatory response syndrome (SIRS), multiple organ failure (POF) and even death. The study aimed to investigate the diagnostic value of C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6) and lactate dehydrogenase (LDH) in patients with severe AP.

METHODS

AP patients (n = 153) divided into mild AP patients (n = 81) and severe AP patients (n = 72) were selected from June 2014 to June 2016. The demographic information (age, sex) and the hematological parameters (WBC, PLT, CRP, PCT, IL-6, LDH and so on) were analyzed.

RESULTS

Significant differences were found out of CRP, PCT, IL-6 and LDH values between AP patients and controls (P < 0.05), even those results had significant difference between MAP group and SAP group (P < 0.05). In SAP group, the cut-off values of CRP, PCT, IL-6 and LDH were 16.62, 2.29, 16.66, 273.04; sensitivity 55.6%, 77.8%, 80.2%, 82.7%; specificity 73%, 94%, 85%, 96% and AUC 0.637, 0.929, 0.886, 0.919, respectively. The AUC of combined detection of CRP, PCT, IL-6 and LDH was 0.989 (95%CI).

CONCLUSION

The combined detection of CRP, PCT, IL-6 and LDH has a high diagnostic value for judging the severity of AP.

Acute pancreatitis in Chile: A multicenter study on epidemiology, etiology and clinical outcome. Retrospective analysis of clinical files

BACKGROUND

Epidemiology of acute pancreatitis (AP) is variable in different geographical regions.

OBJECTIVES

To compare etiology and severity of AP to published data from South America and the rest of world, study impact of demographical factors and treatment on its outcome in Chilean hospitals.

METHODS

Multicenter observational study. Data of consecutive patients with AP were collected at the moment of discharge from 11 centers and retrospectively analyzed.

RESULTS

Data of 962 patients were included in the analysis, 447 men and 515 women. Mean age was 48,2 years. Biliary etiology was significantly more frequent in women (70%) than in men (52%). Conversely, alcohol was responsible for about 17% of AP in men but exceptional in women. Mild AP was seen in 73.4%, moderately severe in 14.1% and severe in 13%. The overall mortality was 2.5% (24 of 962): 0.3%, 3.1% and 15.1% in mild, moderately severe and severe cases, respectively. No difference was found in the mortality and severity of biliary versus alcoholic AP, while hypertriglyceridemia induced AP was more severe, without increased mortality. Severity and mortality increased with age. ERCP was performed in 16% of biliary pancreatitis. Adherence to main guidelines was heterogeneous: more than half of mild AP patients were admitted to critical care units and antibiotics were used in about 25% them.

CONCLUSION

This is the first multicenter study in Chile on AP. When compared to literature, we found similar severity distribution and an acceptably low mortality. Biliary etiology was dominant, but alcohol was also important in men.

Evaluation of four scoring systems in prognostication of acute pancreatitis for elderly patients

BACKGROUND

To evaluate the ability of four scoring systems (Ranson, BISAP, Glasgow, and APACHE II) to predict outcomes of acute pancreatitis (AP) in elderly patients.

METHODS

This was a retrospective study of 918 patients presenting with AP at Zhongda Hospital Southeast University, from January 2015 to December 2018. We divided patients into two groups: 368 patients who were ≥ 60 years old, and 550 patients who were < 60 years old. Four scoring systems were used to analyze all patients.

RESULTS

The severity of the disease, and mortality were significantly different between the two groups (p < 0.05), while the difference between the two groups about pancreatic necrosis is statistically insignificant (p = 0.399). The differences of the AUCs (Area under curves) for prediction of outcome of SAP (severe acute pancreatitis) between the two groups were statistically significant for Ranson and APACHE II (p < 0.05), but not for the differences between BISAP and Glasgow. All the four scoring systems were similar in terms of prediction of pancreatic necrosis and death in both groups.

CONCLUSIONS

Prediction of severity, pancreatic necrosis, and death in AP for elderly patients can be performed very well by using BISAP. APACHE II is more suitable for younger patients when dealing with severity. Ranson and Glasgow can be used to evaluate all AP patients in most cases; however, Ranson is more effective for younger patients when used to assess severity.

Radiation dose from computed tomography in patients with acute pancreatitis: an audit from a tertiary care referral hospital

BACKGROUND

There is a limited data on the radiation dose from computed tomography (CT) in patients with acute pancreatitis (AP). The present study evaluated the radiation dose from CT scans in patients with AP.

MATERIAL

A retrospective review of CT reports of patients with AP was conducted. The type of CT scan (non-contrast vs. single-phase vs. biphasic CT) was recorded. The mean number of CT scans and cumulative radiation dose was calculated. The indications and abnormalities on biphasic CT scans were recorded. The radiation doses between different types of the scan were compared.

RESULTS

495 CT studies in 351 patients were evaluated. In patients (n = 78, 22.2%) undergoing multiple CT scans, mean number of CT scans per patient and mean radiation dose were 2.64 ± 1.18 (range 2-9) and 24 ± 15 mSv (range 8.3-79.8 mSv), respectively. The mean radiation dose was significantly greater in patients with modified CT severity index ≥ 8 (n = 63) [25.08 mSv vs. 18.96 mSv, (P = 0.048)]. 61 (12.32%) biphasic scans were performed. A definite indication for a biphasic CT scan was identified in 20 (32.7%) patients. Arterial abnormalities were detected in 6 (9.8%) patients undergoing CT for defined indication. Mean radiation dose in this group was 13.26 ± 7.64 mSv (range 3.42-38.27 mSv) which was significantly greater than the single venous phase scan (7.96 ± 3.48 mSv, P < 0.001).

CONCLUSION

There is a potential for substantial radiation exposure from CT scans to patients with AP. Patients with severe AP and those undergoing biphasic scans have significantly higher radiation exposure. Hence, routine arterial phase acquisition should be avoided.

Nonaggressive Versus Aggressive Intravenous Fluid Therapy in Acute Pancreatitis With More Than 24 Hours From Disease Onset: A Randomized Controlled Trial

OBJECTIVE

This study aimed to compare a "nonaggressive" hydration versus an "aggressive" hydration using Hartmann's solution in patients with acute pancreatitis (AP) with more than 24 hours from disease onset.

METHODS

We included 88 patients with AP with more than 24 hours from disease onset, and were randomized into 2 groups. Group I (n = 45) received a nonaggressive hydration (Hartmann's solution at 1.5 mL kg h for the first 24 hours and 30 mL kg during the next 24 hours), and group II (n = 43) received an aggressive hydration (bolus of Hartmann's solution 20 mL kg, followed by an infusion of 3 mL kg h for the first 24 hours and then 30 mL kg for the next 24 hours).

RESULTS

The mean volume of fluid administered was greater in group II (P < 0.001). We did not find differences when comparing both groups in reference to persistent systemic inflammatory response syndrome (P = 0.528), pancreatic necrosis (P = 0.710), respiratory complications (P = 0.999), acute kidney injury (P = 0.714), or length of hospital stay (P = 0.892).

CONCLUSIONS

Our study suggests that the clinical evolution of patients with AP with more than 24 hours from disease onset is similar using an aggressive or nonaggressive hydration.

Preliminary report on the safety and utility of a novel automated mechanical endoscopic tissue resection tool for endoscopic necrosectomy: a case series

Background and study aims  Endoscopic drainage of walled-off necrosis and subsequent endoscopic necrosectomy has been shown to be an effective step-up management strategy in patients with acute necrotizing pancreatitis. One of the limitations of this endoscopic approach however, is the lack of dedicated and effective instruments to remove necrotic tissue. We aimed to evaluate the technical feasibility, safety, and clinical outcome of the EndoRotor, a novel automated mechanical endoscopic tissue resection tool, in patients with necrotizing pancreatitis. Methods  Patients with infected necrotizing pancreatitis in need of endoscopic necrosectomy after initial cystogastroscopy, were treated using the EndoRotor. Procedures were performed under conscious or propofol sedation by six experienced endoscopists. Technical feasibility, safety, and clinical outcomes were evaluated and scored. Operator experience was assessed by a short questionnaire. Results  Twelve patients with a median age of 60.6 years, underwent a total of 27 procedures for removal of infected pancreatic necrosis using the EndoRotor. Of these, nine patients were treated de novo. Three patients had already undergone unsuccessful endoscopic necrosectomy procedures using conventional tools. The mean size of the walled-off cavities was 117.5 ± 51.9 mm. An average of two procedures (range 1 - 7) per patient was required to achieve complete removal of necrotic tissue with the EndoRotor. No procedure-related adverse events occurred. Endoscopists deemed the device to be easy to use and effective for safe and controlled removal of the necrosis. Conclusions  Initial experience with the EndoRotor suggests that this device can safely, rapidly, and effectively remove necrotic tissue in patients with (infected) walled-off pancreatic necrosis.

Meta-analysis and field synopsis of genetic variants associated with the risk and severity of acute pancreatitis

Background

Genetic risk factors can provide insight into susceptibility for acute pancreatitis (AP) and disease progression towards (infected) necrotizing pancreatitis and persistent organ failure. The aim of the study was to undertake a systematic review of the genetic evidence for AP.

Methods

Online databases (MEDLINE, Embase, BIOSIS, Web of Science, Cochrane Library) were searched to 8 February 2018. Studies that reported on genetic associations with AP susceptibility, severity and/or complications were eligible for inclusion. Meta‐analyses were performed of variants that were reported by at least two data sources. Venice criteria and Bayesian false‐discovery probability were applied to assess credibility.

Results

Ninety‐six studies reporting on 181 variants in 79 genes were identified. In agreement with previous meta‐analyses, credible associations were established for SPINK1 (odds ratio (OR) 2·87, 95 per cent c.i. 1·89 to 4·34), IL1B (OR 1·23, 1·06 to 1·42) and IL6 (OR 1·64, 1·15 to 2·32) and disease risk. In addition, two novel credible single‐nucleotide polymorphisms were identified in Asian populations: ALDH2 (OR 0·48, 0·36 to 0·64) and IL18 (OR 1·47, 1·18 to 1·82). Associations of variants in TNF, GSTP1 and CXCL8 genes with disease severity were identified, but were of low credibility.

Conclusion

Genetic risk factors in genes related to trypsin activation and innate immunity appear to be associated with susceptibility to and severity of AP.

Chronic pancreatitis in children: treat like an adult?

A 15-year-old boy with a medical background of obesity, familial hyperlipidemia and acute recurrent pancreatitis, presented to emergency department reporting a 3-day course of periumbilical abdominal pain and nausea. Pain was noticed on epigastric palpation. Laboratory evaluation revealed leucocytosis, neutrophilia and pancreatic enzymes elevation more than three times the upper limit of normal. An acute recurrence of pancreatitis was diagnosed, was admitted to the hospital, being discharged after 5 days. Four days after, he was readmitted because of symptoms recurrence. Elevation of transaminases, gamma-glutamyltransferase (GGT) and direct bilirubin were noticed. Pancreatic enzymes still elevated but lower than in the previous episode. An endoscopic ultrasound revealed a Wirsung with a cephalic stricture and diffuse structural abnormalities suggestive of chronic pancreatitis. The patients was submitted to endotherapy with several sessions of endoscopic retrograde cholangiopancreatography including stenting and pancreatoscopy with marked clinical and imaging improvement. A genetic variant was identified.

Endoscopic Management of Pancreaticopleural Fistula in a Child with Hereditary Pancreatitis

Pancreaticopleural fistula (PPF) a fistulous connection between the pancreas and pleural space due to prolonged chronic pancreatitis (CP). PPF is a very rare complication which presents in 0.4% of chronic pancreatitis cases, especially among children. We report a case involving a 3-year-old boy who presented with pleural effusion caused by a PPF, a complication of hereditary pancreatitis, which was, for the first time in Korea, successfully managed with endoscopic treatment. Chest radiography and computed tomography showed massive pleural effusion. Percutaneous catheter drainage was performed. High amylase levels were observed in the pleural fluid and serum, suggesting PPF. The patient was managed with bowel rest and octreotide infusion. Endoscopic retrograde cholangiopancreatography revealed CP, and pleural effusion was successfully managed with stent placement. PRSS1 genetic screening revealed R122H mutation.

Risk and Outcomes of Clostridium difficile Infection With Chronic Pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is associated with high rates of recurrent hospitalizations, which predisposes to Clostridium difficile infection (CDI). We investigate the burden of CDI in CP.

METHODS

We identified records of patients with CP from the Nationwide Inpatient Sample (NIS) 2012-2014 and estimated the impact of CDI on their outcomes. We calculated the adjusted odds ratio (AOR) of CP on having CDI (NIS 2014). From NIS 2007-2014, we plotted the trends of CDI and its interaction with CP.

RESULTS

From 2012 to 2014, 886 (2.72%) of the 32,614 CP patients had concomitant CDI, which was associated with poorer outcomes: acute kidney injury (AOR, 2.57 [95% confidence interval {CI}, 2.11-3.13]), length of stay (13.3 vs 7.4 days), and charges (US $127,496 vs US $72,767), but not mortality (AOR, 0.93 [95% CI, 0.28-3.05]). In 2014, CP was associated with an increased risk of CDI (crude odds ratio, 2.10 [95% CI, 1.95-2.26]), which persisted after multivariate adjustment (AOR, 2.03 [95% CI, 1.87-2.19]). From 2007 to 2014, the annual prevalence of CDI was 106.4 cases per 10,000 hospitalizations, increasing from 2007 (95.5/10,000) to 2014 (118.4/10,000), with a 3.7 times higher annual rate of increase among CP versus no-CP patients (13.4/10,000 vs 3.7/10,000 population/year).

CONCLUSIONS

Chronic pancreatitis patients have high burden of CDI and may benefit from CDI prophylaxis.

Low Serum Ionized Calcium, Elevated High-Sensitivity C-Reactive Protein, Neutrophil-Lymphocyte Ratio, and Body Mass Index (BMI) Are Risk Factors for Severe Acute Pancreatitis in Patients with Hypertriglyceridemia Pancreatitis

Background

To investigate the clinical characteristics of hypertriglyceridemia pancreatitis (HTGP) and evaluate the correlative risk factors for severe acute pancreatitis (SAP) in HTGP patients.

Material/Methods

A total of 1005 patients with acute pancreatitis (AP) admitted to Peking Union Medical College Hospital (PUMCH) from 1 Jan 2013 to 1 Aug 2018 were retrospectively reviewed. After screening, we enrolled 159 patients with HTGP and 172 with non-hypertriglyceridemia pancreatitis (NHTGP). We gathered and assessed demographic and blood biochemical information and analyzed the risk factors for SAP.

Results

Age, serum amylase (AMY), lipase (LIP), and serum ionized calcium (Ca²⁺) in the HTGP group were lower than in the NHTGP group (P<0.05), while high-sensitivity C-reactive protein (hsCRP), neutrophil–lymphocyte ratio (NLR), and body mass index (BMI) in the HTGP group were higher than in the NHTGP group (P<0.05). Among the HTGP patients, the results indicated that Ca²⁺ (OR=0.018, P<0.001, 95%CI: 0.002–0.129) was an independent protective factor for SAP, while higher CRP (OR=1.008, P=0.004, 95%CI: 1.003–1.013), NLR (OR=1.314, P<0.001, 95%CI: 1.161–1.488), and BMI (OR=1.597, P=0.002, 95%CI: 1.195–2.314) were independent risk factors for SAP.

Conclusions

Patients with HTGP had lower serum Ca²⁺ and higher hsCRP, NLR, and BMI, and these were associated with higher risk of developing SAP.

Acute pancreatitis in end-stage renal disease patients in the USA: a nationwide, propensity score-matched analysis

BACKGROUND

Limited data exist regarding the effects of end-stage renal disease (ESRD) on acute pancreatitis (AP). This study aimed to evaluate the association between ESRD and outcomes and resource utilization of AP.

MATERIALS AND METHODS

The 2014 National Inpatient Sample database was used to identify all hospitalized patients with a principal diagnosis of AP. Propensity score matching was performed to create a matched cohort of ESRD and non-ESRD patients. The in-hospital mortality, morbidity, resource utilization and expenditures of AP in ESRD patients were compared to non-ESRD patients. Multivariate analysis was performed for further adjustment for potential confounders.

RESULTS

Of 382 595 AP patients, 7380 ESRD patients and 8050 non-ESRD patients were created after propensity score matching. ESRD patients had more tendency to have hypercalcemia-related or AP-related to other/unspecified causes, whereas non-ESRD patients had more tendency to have alcohol-related, gallstone-related, and hypertriglyceridemia-related AP. In multivariate analysis, ESRD was associated with increased in-hospital mortality, increased length of hospital stay, and increased hospitalization costs and charges. No differences were observed in inpatient morbidity, imaging study use, and procedures performed during hospitalization.

CONCLUSION

In this large nationwide study using inpatient USA database, we demonstrate higher AP-related mortality, and resource utilization among ESRD patients when compared with non-ESRD patients.

Pancreatitis in Children

Acute, acute recurrent, and chronic forms of pancreatitis have been increasingly diagnosed in children in the past 2 decades. Risk factors in the pediatric group are broad and appear to be strikingly different compared with the adult cohort. However, the disease burden and impact on quality of life are surprisingly similar in children and adults. This review summarizes the definitions, epidemiology, risk factors, diagnosis, and management of pediatric pancreatitis, identifies features that are unique to the childhood-onset disease, identifies gaps, and proposes recommendations for future opportunities.

Aging and Comorbidities in Acute Pancreatitis I: A Meta-Analysis and Systematic Review Based on 194,702 Patients

Background: Acute pancreatitis (AP) is one of the most common cause of hospitalization among gastrointestinal diseases worldwide. Although most of the cases are mild, approximately 10-20% of patients develop a severe course of disease with higher mortality rate. Scoring systems consider age as a risk factor of mortality and severity (BISAP; >60 years, JPN>70 years, RANSON; >55 years, APACHE II >45 years). If there is a correlation between aging and the clinical features of AP, how does age influence mortality and severity? Aim: This study aimed to systematically review the effects of aging on AP. Methods: A comprehensive systematic literature search was conducted in the Embase, Cochrane, and Pubmed databases. A meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis statement (PRISMA). A total of 1,100 articles were found. After removing duplicates and articles containing insufficient or irrelevant data, 33 publications involving 194,702 AP patients were analyzed. Seven age categories were determined and several mathematical models, including conventional mathematical methods (linear regression), meta-analyses (random effect model and heterogeneity tests), meta-regression, funnel plot and Egger's test for publication bias were performed. Quality assessment was conducted using the modified Newcastle-Ottawa scale. The meta-analysis was registered in the PROSPERO database (CRD42017079253). Results: Aging greatly influences the outcome of AP. There was a low severe AP incidence in patients under 30 (1.6%); however, the incidence of severe AP showed a continuous, linear increase between 20 and 70 (0.193%/year) of up to 9.6%. The mortality rate was 0.9% in patients under 20 and demonstrated a continuous linear elevation until 59, however from this age the mortality rate started elevating with 9 times higher rate until the age of 70. The mortality rate between 20 and 59 grew 0.086%/year and 0.765%/year between 59 and 70. Overall, patients above 70 had a 19 times higher mortality rate than patients under 20. The mortality rate rising with age was confirmed by meta-regression (coefficient: 0.037 CI: 0.006-0.068, p = 0.022; adjusted r2: 13.8%), and severity also (coefficient: 0.035 CI: 0.019-0.052, p < 0.001; adjusted r2: 31.6%). Conclusion: Our analysis shows a likelihood of severe pancreatitis, as well as, pancreatitis-associated mortality is more common with advanced age. Importantly, the rapid elevation of mortality above the age of 59 suggests the involvement of additional deteriorating factors such as co-morbidity in elderly.

Aging and Comorbidities in Acute Pancreatitis II.: A Cohort-Analysis of 1203 Prospectively Collected Cases

Introduction: Our meta-analysis indicated that aging influences the outcomes of acute pancreatitis (AP), however, a potential role for comorbidities was implicated, as well. Here, we aimed to determine how age and comorbidities modify the outcomes in AP in a cohort-analysis of Hungarian AP cases. Materials and Methods: Data of patients diagnosed with AP by the revised Atlanta criteria were extracted from the Hungarian Registry for Pancreatic Patients. Outcomes of interest were mortality, severity, length of hospitalization, local, and systemic complications of AP. Comorbidities were measured by means of Charlson Comorbidity Index (CCI) covering pre-existing chronic conditions. Non-parametric univariate and multivariate statistics were used in statistical analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: A total of 1203 patients from 18 centers were included. Median age at admission was 58 years (range: 18-95 years), median CCI was 2 (range: 0-10). Only severe comorbidities (CCI ≥ 3) predicted mortality (OR = 4.48; CI: 1.57-12.80). Although severe comorbidities predicted AP severity (OR = 2.10, CI: 1.08-4.09), middle (35-64 years) and old age (≥65 years) were strong predictors with borderline significance, as well (OR = 7.40, CI: 0.99-55.31 and OR = 6.92, CI: 0.91-52.70, respectively). Similarly, middle and old age predicted a length of hospitalization ≥9 days. Interestingly, the middle-aged patients (35-64 years) were three times more likely to develop pancreatic necrosis than young adults (OR = 3.21, CI: 1.26-8.19), whereas the old-aged (≥65 years) were almost nine times more likely to develop systemic complications than young adults (OR = 8.93, CI: 1.20-66.80), though having severe comorbidities (CCI ≥ 3) was a predisposing factor, as well. Conclusion: Our results proved that both aging and comorbidities modify the outcomes of AP. Comorbidities determine mortality whereas both comorbidities and aging predict severity of AP. Regarding complications, middle-aged patients are the most likely to develop local complications; in contrast, those having severe comorbidities are prone to develop systemic complications. Studies validating the implementation of CCI-based predictive scores are awaited.

The association between obesity and outcomes in acute pancreatitis: an individual patient data meta-analysis

OBJECTIVES

There are data to suggest that obesity is associated with local and systemic complications as well as mortality in acute pancreatitis (AP). Cohort studies to date, however, have shown conflicting results from mostly unadjusted analyses. Therefore, we performed an individual patient data meta-analysis with the primary aim to investigate the association between obesity and mortality in AP. Our secondary aim was to investigate the association between obesity and necrosis, organ failure, multiple organ failure, and invasive intervention.

PATIENTS AND METHODS

We systematically searched four electronic databases for prospective studies on obesity and outcomes in AP. Researchers of eligible studies were invited to share individual patient data using a standardized data collection form. All end points were investigated with a one-stage mixed effects Poisson model with random intercepts and forced entry of relevant confounders.

RESULTS

We included five databases with 1302 patients, of whom 418 (32%) were obese. In total, 466 (36%) patients had necrosis, 328 (25%) had organ failure, 188 (14%) had multiple organ failure, 210 (16%) had an intervention, and 84 (7%) patients died. We found no significant association between obesity and mortality [relative risk (RR) 1.40, 95% confidence interval (CI): 0.89-2.20], necrosis (RR: 1.08, 95% CI: 0.90-1.31) or invasive intervention (RR: 1.10, 95% CI: 0.83-1.47) after adjustment for confounders. However, obesity was independently associated with the development of organ failure (RR: 1.38, 95% CI: 1.11-1.73) and multiple organ failure (RR: 1.81, 95% CI: 1.35-2.42).

CONCLUSION

Obesity is independently associated with the development of organ failure and multiple organ failure in AP. However, there is no association between obesity and mortality, necrosis, and an intervention.