Acute Pancreatitis Review

Beyond the Basics: Recommended Approach to Severe Acute Pancreatitis Management in the Critical Care Setting

Acute Pancreatitis (AP) poses a significant healthcare burden globally. While most cases present with a mild course, approximately one-fifth progress to severe forms characterized by severe pancreatitis and systemic complications, leading to a mortality rate of up to 40%. Effective management of severe acute pancreatitis necessitates a multidisciplinary approach involving gastroenterologists, interventional radiologists, intensive care teams, and surgeons. The advances in treatment modalities, including early hydration, nutrition, and pain control, have led to a decrease in the morbidity and long-term complications associated with severe acute pancreatitis down to 20%. In this review, we focus on the management challenges and outcomes associated with the difficult condition of severe acute pancreatitis.

Association between estimated plasma volume status and the risk of 30-day mortality in patients with severe acute pancreatitis: a retrospective study based on the MIMIC-IV database

BACKGROUND

Assessing plasma volume is important in the management and treatment of severe acute pancreatitis (SAP). Although it is an easy and rapid method for estimating the plasma volume, the association between estimated plasma volume status (ePVS) and the prognosis of SAP remains elusive. This study was aimed at assessing the relationship of ePVS with the risk of 30-day all-cause mortality (ACM) in SAP patients.

METHODS

This study collected clinical data on SAP patients in the ICU from the MIMIC-IV database. LASSO regression was used to screen for relevant covariates. The nonlinear relationship of ePVS with the risk of 30-day ACM was assessed utilizing the restricted cubic spline (RCS) analysis, and then their association was assessed by a multivariate Cox regression model. 30-day survival across different groups was compared by a Kaplan-Meier survival curve.

RESULTS

This study included 1036 patients, with a 30-day survival rate of 86.8%. They were assigned to four groups by quartiles of ePVS. The Kaplan-Meier survival curve showed that the high ePVS group was at a higher risk of 30-day ACM (p = 0.007). Multivariate Cox regression analysis showed a positive association of ePVS as a continuous variable with the risk of 30-day ACM (HR = 1.09, 1.01-1.18, p = 0.035). The risk of 30-day ACM was higher in the Q4 group vs. the Q1 group with ePVS as a categorical variable (HR = 1.70, 95% CI: 1.03-2.80, p = 0.039). RCS analysis showed a linear relationship of ePVS with the risk of 30-day ACM (p = 0.606), with a cut-off value of 6.23 dL/g. Subgroup analysis revealed significant associations between the two within specific subgroups, but ePVS did not interact with any of the subgroup variables.

CONCLUSION

Our findings showed a significant association of high ePVS values with an increased risk of 30-day ACM. This study helps to identify high-risk patients early and guide the development of personalized treatment strategies.

Effect of biliopancreatic tree anatomy on development of acute gallstone pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a complex disorder with gallstones being the most common underlying cause. Anatomical variations of gallbladder, cystic duct (CD), common bile duct and main pancreatic duct and their courses and interactions with each other have been studied and shown to be related to development of AP in various studies. With this study, we aimed to investigate the relationship between biliopancreatic tree anatomy and acute gallstone pancreatitis.

MATERIALS AND METHODS

157 gallstone related AP patients and 75 control group patients were enrolled in the study. The level at which cystic duct opened to common bile duct (as in proximal-mid-distal 1/3) and type of cystic duct course and opening (parallel to CBD, perpendicular to CBD, straight anatomy, tortuous anatomy) were evaluated from MRCP scans. Additionally, diameters of main pancreatic duct, common bile duct and angles between main pancreatic duct-common bile duct and cystic duct-common bile duct were calculated.

RESULTS

All investigated parameters except CD opening angle were statistically significantly different between two groups. MPD opening angle was more acute in the control group. Parallel and tortuous CD was more common in the patient group. Patients with acute gallstone pancreatitis were more likely to have CD opening to the second and third parts of CBD.

CONCLUSION

Anatomy of the biliopancreatic tree and its variations are related to acute gallstone pancreatitis. Several proposed mechanism are thought to play role in this phenomenon but future prospective studies are required to reveal more on the topic.

Therapeutic Effects of Esomeprazole on Pancreatic and Lung Injury in Acute Pancreatitis: An Experimental Study

Background and Objectives: During acute pancreatitis, leakage of pancreatic enzymes into the gland results in autolysis of the pancreas. The lungs are also involved in this process. This study aimed to investigate the therapeutic effects of esomeprazole on damaged pancreatic tissue and affected lung tissue in rats with acute pancreatitis. Materials and Methods: The 24 Wistar-Albino male rats were divided into three groups: Control group (2 mL 0.9% saline solution was given intraperitoneally, n = 8); PCT group (acute pancreatitis was induced and then 2 mL 0.9% saline solution was administered intraperitoneally, n = 8); ESM group (acute pancreatitis was induced and then 10 mg/kg esomeprazole was administered intraperitoneally, n = 8). Then, the lungs and pancreas were completely removed, and blood samples were taken from all rats for histopathological and biochemical examination. Results: Pancreatic edema, vacuolization, necrosis, and inflammation in the PCT group were higher than in the control and ESM groups. Alveolar edema, alveolar distension, alveolar PMNL infiltration, and alveolar wall thickness in the PCT group were higher than in the control and ESM groups. Furthermore, IL-β (F = 40.137, p < 0.001), TNF-α (F = 40.132, p < 0.001), MIP-2 (X2 = 19.245, p < 0.001), ICAM-1 (F = 14.312, p < 0.001), NO (F = 25.873, p < 0. 001), amylase (F = 30.333, p < 0.001), and lipase (X2 = 16.141, p < 0.001) values measured in serum were different among groups. Pairwise group comparisons revealed that IL-β, TNF-α, MIP-2, and amylase levels in the ESM group were lower than in the PCT group (p < 0.05). Conclusions: Esomeprazole could be recommended in clinical practice during acute pancreatitis treatment due to its therapeutic effects on damaged pancreatic and lung tissues secondary to pancreatitis in rats.

Efficacy of 2-Mercaptoethane Sulfonate Sodium (MESNA) in the Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Randomized Open Label Trial

Background and Aim

Oxidative stress has been considered a factor in the development of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The present clinical trial evaluated whether adding intravenous mesna to rectal indomethacin could prevent or alleviate PEP.

Methods

An open-labeled clinical trial was done on 698 participants undergoing endoscopic retrograde cholangiopancreatography (ERCP). Eligible patients received 100 mg indomethacin suppository 30 min before undergoing ERCP. Randomly, the participants received 400 mg intravenous mesna or nothing 30 min before doing the procedure. The PEP incidence and degree were measured in the patients as the main outcome.

Results

The total rate of PEP was equal to 13.7%. No significant difference was seen in the rate and severity of PEP between the mesna plus indomethacin and indomethacin alone arms (14% vs. 13.4%, respectively, p = 0.671). In high-risk patients, PEP rate and severity were lower in the mesna plus indomethacin group compared with indomethacin alone group and the statistical analysis showed that the difference was significant (41.7% vs. 51.8%, respectively, p = 0.033).

Conclusion

In high-risk patients undergoing ERCP, a combination of intravenous mesna plus rectal indomethacin may decrease the PEP rate and severity.

Embryonic Lethal Abnormal Visual-Like Protein 1 Aggravates Caerulein-Induced AR42J Cell Injury and Macrophage M1 Polarization to Accelerate Acute Pancreatitis by Upregulating TRAF6

Tumor necrosis factor receptor-associated factor 6 (TRAF6) has been found to promote the progression of acute pancreatitis (AP). However, its underlying molecular mechanisms in AP need to be further revealed. Caerulein-induced AR42J cells were used to construct AP cell models. Cell viability and apoptosis were measured by Cell Counting Kit 8 assay and flow cytometry. Levels of inflammatory factors and oxidative stress-related markers were assessed. The medium of AR42J cells was collected for coculturing RAW264.7 cells. Macrophage marker CD86+ cell rates were checked with flow cytometry. The levels of TRAF6, embryonic lethal abnormal visual-like protein 1 (ELAVL1), and inducible nitric oxide synthase (iNOS) were examined by Western blot or quantitative real-time polymerase chain reaction. RNA immunoprecipitation assay was performed to evaluate the interaction between ELAVL1 and TRAF6. TRAF6 mRNA stability was tested using actinomycin D treatment. Caerulein treatment suppressed viability, induced AR42J cell apoptosis, inflammation, oxidative stress, and accelerated macrophage M1 polarization. TRAF6 downregulation could alleviate caerulein-induced AR42J cell injury and macrophage M1 polarization. ELAVL1 interacted with TRAF6 to stabilize its expression. Meanwhile, ELAVL1 knockdown relieved caerulein-induced AR42J cell injury and macrophage M1 polarization, while these effects were abolished by TRAF6 overexpression. TRAF6, stabilized by ELAVL1, promoted caerulein-induced AR42J cell injury and macrophage M1 polarization, suggesting that it might accelerate AP9 progression.

Development of a nomogram for predicting pancreatic portal hypertension in patients with acute pancreatitis: a retrospective study

INTRODUCTION

Pancreatic portal hypertension (PPH) is a rare complication of acute pancreatitis (AP) that can lead to severe gastrointestinal bleeding. The risk factors associated with PPH, as well as the overall prognosis, warrant further investigation. This study aims to develop and validate a nomogram to predict PPH in patients with AP.

METHODS

Consecutive patients with AP from 2015 to 2023 were retrospectively included in the study. Demographic data, clinical manifestations within the first week of AP onset, and initial contrast-enhanced CT findings were used to develop the predictive model. Univariate and multivariate Cox regression analyses were performed to identify risk factors for PPH. Based on the results of the multivariate analysis, a nomogram was developed. The patients were randomly divided into training and validation sets at a 7:3 ratio. The accuracy and discriminative power of the predictive model were assessed using the area under the curve (AUC) from the receiver operating characteristic curve and the calibration curve.

RESULTS

Of the 1473 patients with AP, 107 (7.3%) developed PPH within 6 months (range: 2-22 months) during follow-up. Multivariate regression analysis showed that body mass index (BMI) (HR, 1.10; 95% CI 1.04 to 1.16; p=0.001), moderately severe grade (HR, 9.36; 95% CI 4.58 to 19.13; p<0.001), severe grade (HR, 12.95; 95% CI 6.22 to 26.94; p<0.001), diabetes (HR, 2.26; 95% CI 1.47 to 3.47; p<0.001), acute fluid accumulation (HR, 2.13; 95% CI 1.31 to 3.47; p=0.002), and necrosis (HR, 3.64; 95% CI 2.30 to 5.78; p<0.001) were independent risk factors for PPH. A nomogram for predicting PPH was developed, with the predictive curves showing an AUC of 0.859 at 6 months and 0.846 at 9 months. In the validation set, the AUC at both time points was 0.812.

CONCLUSION

In summary, we identified BMI, moderately severe or severe AP, diabetes, acute fluid accumulation, and necrosis as risk factors for AP-related PPH. Using the largest cohort of patients with AP to date, we developed a highly accurate nomogram with strong discriminative ability for predicting PPH. Future studies with larger sample sizes are necessary to confirm our findings and conduct external validation.

Association Between Hemoglobin-to-Red Blood Cell Distribution Width Ratio and 30-Day Mortality in Patients with Acute Pancreatitis: Data from MIMIC-III and MIMIC-IV

To investigate the relationship between hemoglobin-to-red blood cell distribution width (RDW) ratio (HRR) and the 30-day mortality risk in acute pancreatitis (AP), and assess the predictive ability of HRR. Data from 2001 to 2019 in the Medical Information Mart for Intensive Care-III/IV (MIMIC-III/IV) were analyzed. The outcome of this retrospective cohort study was 30-day mortality. Hemoglobin-to-RDW ratio (0-24 hours) and HRR (24-48 hours) were divided into 4 groups based on quartiles (Q1, Q2, Q3, and Q4). The predictive effect was evaluated by the C-index. A total of 1736 patients were included, and 30-day mortality occurred in 204 (11.75%) patients. Compared with Q1 of HRR (0-24 hours), Q2 (HR = 0.60, 95% CI : 0.42-0.86), Q3 (HR =0.47, 95% CI : 0.31-0.71), and Q4 (HR = 0.45, 95% CI : 0.29-0.68) of HRR levels reduced the 30-day mortality risk. Hemoglobin-to-RDW ratio (24-48 hours) was consistent with the results of HRR (0-24 hours). For changes in HRR, Q4 for changes in HRR levels (HR = 1.64, 95% CI : 1.09-2.45) increased the 30-day mortality risk. Hemoglobin-toRDW ratio significantly improved the predictive effect of Sequential Organ Failure Assessment (C-index = 0.736) and Bedside Index of Severity in Acute Pancreatitis (C-index = 0.704) on 30-day mortality. Higher HRR levels reduced the 30-day mortality risk in AP and may improve the prediction of other tools.

Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department

BACKGROUND

As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation.

OBJECTIVES

The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP.

METHODS

We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications.

RESULTS

Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91).

CONCLUSION

The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Rational design peptide inhibitors of Cyclophilin D as a potential treatment for acute pancreatitis

Cyclophilin D (CypD) is a mitochondrial matrix peptidyl prolidase that regulates the mitochondrial permeability transition pore. Inhibition of CypD was suggested as a therapeutic strategy for acute pancreatitis. Peptide inhibitors emerged as novel binding ligand for blocking receptor activity. In this study, we present our computational approach for designing peptide inhibitors of CypD. The 3-D structure of random peptides were built, and docked into the active center of CypD using Rosetta script integrated FlexPepDock module. The peptide displayed the lowest binding energy against CypD was further selected for virtual iterative mutation based on virtual mutagenesis and molecular docking. Finally, the top 5 peptides with the lowest binding energy was selected for validating their affinity against CypD using inhibitory assay. We showed 4 out of the selected 5 peptides were capable for blocking the activity of CypD, while WACLQ display the strongest affinity against CypD, which reached 0.28 mM. The binding mechanism between WACLQ and CypD was characterized using molecular dynamics simulation. Here, we proved our approach can be a robust method for screening peptide inhibitors.