Simultaneous acute pancreatitis and angioedema associated with angiotensin-converting enzyme inhibitor

Positive Effect of a Pea-Clam Two-Peptide Composite on Hypertension and Organ Protection in Spontaneously Hypertensive Rats

In the present study, we prepared pea peptides with high angiotensin-converting enzyme (ACE) inhibitory activity in vitro using an enzymatic hydrolysis of pea protein and compounded them with clam peptides to obtain a pea-clam double peptide. The effects of the two-peptide composite and pea peptides on hypertension and the damage-repair of corresponding organs were studied in spontaneously hypertensive rats (SHRs). We found that both pea peptides and the two-peptide composite significantly reduced the blood pressure upon a single or long-term intragastric administration, with the two-peptide composite being more effective. Mechanistically, we found that the two-peptide composite could regulate the renal renin-angiotensin system (RAS), rebalance gut microbial dysbiosis, decrease renal and myocardial fibrosis, and improve renal and cardiac function and vascular remodeling. Additionally, hippocampal lesions caused by hypertension were also eliminated after two-peptide composite administration. Our research provides a scientific basis for the use of this two-peptide composite as a safe antihypertension ingredient in functional foods.

Lisinopril-Induced Acute Necrotizing Pancreatitis

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that is used as one of the first-line antihypertensive medications. Necrotizing pancreatitis induced by the use of ACE inhibitors is an extremely rare occurrence. Although an uncommon risk factor, our aim is to further highlight that patients with chronic use of lisinopril can develop such complications and should be considered among the list of differential diagnoses for pancreatitis. A 53-year-old Caucasian male with a history of hypertension treated with lisinopril presented with a one-day history of nausea, vomiting, and severe epigastric pain. On physical examination, there was tenderness to palpation in the epigastric region and left lower quadrant without rebound tenderness or guarding. A complete blood count showed a slight increase in white blood cell count to 12,000 cells/mm³ and serum lipase level was elevated at 1028 U/L. A subsequent CT scan of the abdomen with contrast revealed findings supporting necrotizing pancreatitis. The patient was treated with conservative medical management with goal-directed intravenous fluid support, early enteral feeding, and pain control. His condition resolved, and he was found doing well on follow-up visits.

Angiotensin-Converting Enzyme (ACE) Inhibitors and Pancreatitis: A Potential Dose-dependent Relationship

Acute pancreatitis (AP) remains one of the most common causes of emergency department visits in the USA. The literature supports an association between angiotensin-converting enzyme inhibitors (ACEi), mainly at steady-state doses, and AP^[1]. We present a case of recurrent AP and pseudocyst formation following multiple ACEi dose adjustments after a steady-state period lasting for over a decade. Previous reports have rarely described ACEi-induced pancreatitis and pseudocyst development. ACEi can cause significant ductal obstruction^[2] and fluid retention due to its angioedema effects. Consequently, it may trigger AP complicated by pseudocyst formation. Therefore, ACEi administration must be considered in the appropriate clinical context.

LEARNING POINTS

Although rare, ACEi is an emerging cause of drug-induced pancreatitis and often goes unrecognized.Multiple dose changes within a short period of time can lead to acute drug-induced pancreatitis (DIP), in addition to classic DIP caused by steady-state doses.ACEi-induced angioedema damages the ductal architecture and also has longer-lasting effects such as pseudocyst formation.

Angiotensin-II and acute pancreatitis

Acute pancreatitis (AP) is one of the most common acute abdominal diseases in the digestive system. The total mortality of AP is about 5%-10%; however, the mortality of severe acute pancreatitis (SAP) is about 30%-40%. In recent years, the overall mortality rate of AP has not changed much, but the incidence rate of AP is increasing year by year. AP has become the second major cause of hospitalization in department of gastroenterology, and also is one of the most expensive diseases. According to the revised Atlanta classification criteria in 2012, AP can be divided into mild acute pancreatitis (MAP), moderate severe acute pancreatitis (MSAP), and SAP. About 60% of AP cases are MAP, which is often self-limited, has no complications, and is associated with a low mortality rate; however, about 30% of AP patients had MSAP, about 10% of which could get worse to turn to SAP. Persistent organ failure (POF) is the main cause of the progression of SAP, and also is the main cause of death in the early stage of AP. Pancreatic necrosis with secondary infection is the main cause of death in the late stage of AP. The progression and prognosis of AP are closely related to the early treatment and intervention, but the complicated pathogenesis of AP affects the efficacy of early treatment. Since the pathogenesis of AP has not been fully elucidated, there is a lack of specific treatment. At present, the pathogenesis of AP is generally recognized as "cascade waterfall of leukocyte over-activation-inflammatory factors", "intestinal bacterial translocation and secondary attack", "apoptosis", "pancreatic microcirculation disorder", etc. These theories indicate that the pathogenesis of AP is a complex and multifactorial pathophysiological process. In recent years, the role of angiotensin-Ⅱ (Ang-Ⅱ), an active substance in the renin-angiotensin system, in the occurrence and development of AP has gradually attracted the attention of scholars. Therefore, an in-depth study of the relationship between Ang-Ⅱ and AP may contribute to the clinical understanding and treatment of AP. In this paper, we review the relationship between Ang-Ⅱ and AP.