Prediction of Admission to Intensive Care Unit and 1-Year Mortality After Acute Pancreatitis With Walled-Off Pancreatic Necrosis: A Retrospective, Single-Center Cohort Study

BACKGROUND AND AIMS

Pancreatic walled-off necrosis (WON) carries significant mortality and morbidity risks, often necessitating intensive care unit (ICU) admission. This retrospective study aimed to evaluate whether routine biochemical parameters at the time of the index endoscopic procedure could predict ICU admission and 1-year mortality following endoscopic treatment of WON.

MATERIALS AND METHODS

We retrospectively identified 201 consecutive patients who underwent endoscopic drainage for WON between January 1, 2010, and December 31, 2020. Associations between routine biochemical blood tests and outcomes were assessed using logistic regression models.

RESULTS

Within 1 year of the index endoscopy, 31 patients (15.4%) died, and 40 (19.9%) were admitted to the ICU due to sepsis. Preoperative electrolyte disturbances were more prevalent among ICU-admitted patients and nonsurvivors. Hyperkalemia, hypoalbuminemia, and elevated urea were significant predictors of 1-year mortality, while hypernatremia, elevated serum creatinine, and hypoalbuminemia predicted ICU admission. Predictive models exhibited good discriminative ability, with an AUC of 0.84 (95% CI,0,75-0.93) for 1-year mortality and 0.86 (95%CI, 0.79-0.92) for ICU admission.

CONCLUSIONS

Preoperative imbalances in routine blood tests effectively predict adverse outcomes in endoscopically treated WON patients.

Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study

BACKGROUNDS

The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP.

MATERIALS AND METHODS

The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed.

RESULTS

From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results.

CONCLUSION

Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.

Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis

Infected necrotizing pancreatitis (INP) is associated with an increased risk of organ failure and mortality. Its early recognition and timely initiation of antibiotic therapy can save patients' lives. We systematically searched three databases on 27 October 2022. In the eligible studies, the presence of infection in necrotizing pancreatitis was confirmed via a reference test, which involved either the identification of gas within the necrotic collection through computed tomography imaging or the examination of collected samples, which yielded positive results in Gram staining or culture. Laboratory biomarkers compared between sterile necrotizing pancreatitis and INP were used as the index test, and our outcome measures included sensitivity, specificity, the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). Within the first 72 hours (h) after admission, the AUC of C-reactive protein (CRP) was 0.69 (confidence interval (CI): 0.62-0.76), for procalcitonin (PCT), it was 0.69 (CI: 0.60-0.78), and for white blood cell count, it was 0.61 (CI: 0.47-0.75). After the first 72 h, the pooled AUC of CRP showed an elevated level of 0.88 (CI: 0.75-1.00), and for PCT, it was 0.86 (CI: 0.60-1.11). The predictive value of CRP and PCT for infection is poor within 72 h after hospital admission but seems good after the first 72 h. Based on these results, infection is likely in case of persistently high CRP and PCT, and antibiotic initiation may be recommended.

A simple new scoring system for predicting the mortality of severe acute pancreatitis: A retrospective clinical study

It is critical to accurately identify patients with severe acute pancreatitis (SAP) in a timely manner. This study aimed to develop a new simplified AP scoring system based on data from Chinese population.We retrospectively analyzed a consecutive series of 585 patients diagnosed with SAP at the Changhai hospital between 2009 and 2017. The new Chinese simple scoring system (CSSS) was derived using logistic regression analysis and was validated in comparison to 4 existing systems using receiver operating characteristic curves.Six variables were selected for incorporation into CSSS, including serum creatinine, blood glucose, lactate dehydrogenase, heart rate, C-reactive protein, and extent of pancreatic necrosis. The new CSSS yields a maximum total score of 9 points. The cut-offs for predicting mortality and severity (discriminating moderately SAP from SAP) were set as 6 points and 4 points respectively. Compared with 4 existing scoring systems, the area under the receiver operating characteristic of CSSS for prediction of mortality was 0.838, similar to acute physiology and chronic health evaluation II (0.844) and higher than Ranson's score (0.702, P < .001), bedside index of severity in acute pancreatitis (0.615), and modified computed tomography severity index (MCTSI) (0.736). For predicting SAP severity, CSSS was the most accurate (0.834), followed by acute physiology and chronic health evaluation II (0.800), Ranson's score (0.702), MCTSI (0.660), and bedside index of severity in acute pancreatitis (0.570). Further, the accuracy of predicting pancreatic infection with CSSS was the highest (0.634), similar to that of MCTSI (0.641).A new prognostic scoring system for SAP was derived and validated in a Chinese sample. This scoring system is a simple and accurate method for prediction of mortality.

Association of elevated serum triglyceride levels with a more severe course of acute pancreatitis: Cohort analysis of 1457 patients

BACKGROUND

Previous publications have reported an association between hypertriglyceridemia (HTG) and severity of acute pancreatitis, but this relationship remains somewhat controversial.

OBJECTIVE

To evaluate the outcome of acute pancreatitis according to serum triglyceride levels on admission.

METHODS

Retrospective analysis of prospectively collected data, which included all consecutive cases of acute pancreatitis admitted to a tertiary hospital (January 2002-December 2014). Acute pancreatitis patients were classified into 3 groups based on serum triglyceride levels (mg/dl) measured within 48 h from admission: normal triglycerides-mild HTG (<200); moderate HTG (200-749); severe HTG (≥750). Primary outcomes were the difference in organ failure, pancreatic necrosis, acute peripancreatic collections and mortality among the three groups.

RESULTS

A total of 1,457 cases were included: 1,335 with normal-mild HTG, 77 with moderate HTG and 45 with severe HTG. The rates of organ failure (11.2% in normal-mild HTG group, 15.6% in moderate HTG and 20.0% in severe HTG), persistent multiple organ failure (2.5% vs. 5.2% vs. 6.7%), pancreatic necrosis (9.2% vs. 14.3% vs. 26.7%) and acute collections (21.6% vs. 40.3% vs. 55.6%) increased significantly with hypertriglyceridemia severity grades. On multivariate analysis, triglycerides as a quantitative variable, evaluated in increments of 100 mg/dl, was independently associated with organ failure, pancreatic necrosis, acute collections and mortality (p < 0.05).

CONCLUSIONS

Elevated serum triglyceride levels are independently associated with a more severe course of pancreatitis. It must be highlighted the elevated frequency of local complications in patients with HTG that increases proportionally and significantly with HTG severity grades.

New predictor of acute necrotizing pancreatitis: Red cell distribution width

BACKGROUND

Acute pancreatitis (AP) is inflammation of the pancreas of various severity ranging from mild abdominal pain to mortality. AP may be classified as acute interstitial edematous pancreatitis (AEP) or acute necrotizing pancreatitis (ANP), according to the revised Atlanta criteria. Most of the patients with AP are AEP (75-85% of patients), while 15-25% of patients have ANP. The mortality rate is 3% in AEP and 15% in ANP. Thus, it is important to predict the severity of AP to decrease the morbidity and mortality.

OBJECTIVES

The aim of the study was to evaluate the relationship between red cell distribution width (RDW) and the severity of AP on admission to hospital.

MATERIAL AND METHODS

Patients admitted to Adana Numune Research and Educational Hospital with a diagnosis of AP through the time frame of January 2014-May 2016 were included in our study. Diagnosis of AP was made according to the revised Atlanta classification. Patients' age, sex, etiology of AP, and RDW values were recorded on admission to the hospital.

RESULTS

A total of 180 patients were included in the study. Eighty patients (44%) were male and 100 patients were female. Mean age was 56.25 ±18.3 years (52.66 ±14.4 in males; 59.84 ±20.2 in females). There was no statistically significant difference between patients' age. The most frequently observed etiologic factor was gallstone disease followed by alcohol intake and the use of pharmaceuticals. Drug-related AP was associated with azathioprine, furosemide, and thiazide diuretics. One hundred forty-four (80%) patients had AEP and 36 (20%) patients had ANP. RDW values showed a statistically significant difference between patients with AEP and ANP (p = 0.011). The cut-off value of RDW was 16.4 and the area under curve (AUC) value was 0.591 (p = 0.0227) with a sensitivity of 29.2% and specificity of 89.83%.

CONCLUSIONS

Red cell distribution width could be used to evaluate the prognosis of acute pancreatitis.

Tumor necrosis factor-α and procalcitonin level variations in the serum and their effects on organ function in patients with severe acute pancreatitis during infected stage

To investigate the changes of tumor necrosis factor-α (TNF-α) and procalcitonin (PCT) in the serum and their effects on organ function in patients with severe acute pancreatitis (SAP) during infected stage, aiming to provide a reference to individual treatment. 32 patients with SAP during infected stage admitted to the Digestive Department of The Second Affiliated Hospital of Zhengzhou University from April 2014 to May 2015 and also 30 volunteer normal people were recruited in this study. And 26 patients detected with positive pathogenic bacteria were grouped into group A and another 6 patients with negative pathogenic bacteria into group B and 30 normal people into group C. And TNF-α and PCT level in the serum and the liver, kidney and lung function and the relationship between them of all the included people were compared and analyzed. the serum TNF-α level detected in the bile, urine and the surface of wound in group A was much higher than that in group B (P<0.05); and there was no significant difference in PCT between group A and group B; and TNF-α and PCT level in the serum in group A and group B were remarkably higher than group C (P<0.05). In addition, the organ function (the liver, kidney and lung) in the patients with high TNF-α level (High TNF-α group) was significantly different from the patients with low TNF-α level (Low TNF-α group) (P<0.05). And various organ functional indexes increased significantly in the patients with high PCT level (P<0.05). There were two kinds of TNF-α level (high level and low level) in the patients during SAP general infection stage, and the high level may reduce various organ function, the low level can contribute to the regular inflammatory response. And there is a high PCT level in the early SAP infection stage, which can be used to predict the patients' condition.

Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis

To assess the association between the clinical parameters within 48 hours of admission and the occurrence of infected pancreatic necrosis (IPN) during the late phase of necrotizing pancreatitis (NP).All patients were divided into 2 groups, the IPN and non-IPN groups. The clinical data were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between clinical parameters and IPN secondary to NP. The performance of each independent variable was plotted by the receiver-operating characteristic (ROC) curve. Consequently, the cut-off level of each independent variable with its sensitivity and specificity was calculated.A total of 215 patients were enrolled in our study. Among them, 87 (40.5%) patients developed IPNs after a median of 13.5 (9.5-23.0) days from admission. Multivariate analysis indicated that the level of hematocrit (HCT) from 40% to 50% (P=.012, odds ratio (OR) = 2.407), HCT over 50% (P < .009, OR = 6.794), blood urea nitrogen (BUN) (P = .040, OR = 1.894), C-reactive protein (CRP) (P = .043, OR = 1.837), and procalcitonin (PCT) (P = .002, OR = 2.559) were independent risk factors of IPN secondary to NP. The ROC cures revealed that the area under the ROC (AUC) of the maximum level of HCT, BUN, CRP, and PCT within 48 hours of admission was 0.687, 0.620, 0.630, and 0.674 respectively. Furthermore, the combination of these 4 individual parameters contributes to a more preferable AUC of 0.789 with a sensitivity of 67.8% and specificity of 77.3%.The maximum levels of PCT, CRP, HCT, and BUN within 48 hours of admission are independent factors of IPN and their combination might accurately predict the occurrence of IPN secondary to NP.

Serum Uromodulin Levels in Prediction of Acute Kidney Injury in the Early Phase of Acute Pancreatitis

In health, uromodulin is the main protein of urine. Serum uromodulin concentrations (sUMOD) have been shown to correlate with kidney function. Acute kidney injury (AKI) is among the main complications of severe acute pancreatitis (AP). No reports exist on sUMOD in patients with AP, including the diagnostic usefulness for early prediction of AP severity. We measured sUMOD during first 72 h of AP. Sixty-six adult patients with AP were recruited at the surgical ward of the District Hospital in Sucha Beskidzka, Poland. AP was diagnosed according to the Revised Atlanta Classification. Blood samples were collected at 24, 48 and 72 h of AP, and sUMOD concentrations were measured with enzyme-linked immunosorbent test. sUMOD decreased non-significantly during the study. Patients with severe AP had non-significantly lower sUMOD concentrations than those with mild disease. Significant positive correlation was observed between sUMOD and estimated glomerular filtration rate on each day of the study and negative correlations were shown between sUMOD and age, serum creatinine, cystatin C and urea. Patients with AKI tended to have lower sUMOD. Although sUMOD correlated significantly with kidney function in the early phase of AP, measuring sUMOD did not allow to reliably predict AP severity or development of AKI.

Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis

BACKGROUND

The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels.

MAIN RESULTS

A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice.

AUTHORS' CONCLUSIONS

The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.

Effect of ceramide-1-phosphate transfer protein on intestinal bacterial translocation in severe acute pancreatitis

BACKGROUND AND OBJECTIVE

The aim of the study was to investigate the effects of ceramide-1-phosphate transfer protein (CPTP) on the intestinal epithelial tight junction proteins in patients with severe acute pancreatitis (SAP).

METHODS

Fifty patients with SAP were classified into two groups according to the presence of bacterial translocation (BT) in the blood. Thirty healthy individuals were included in the control group. The presence of BT was analyzed by polymerase chain reaction. The expression of tight junction proteins and CPTP was determined using immunohistochemistry and western blotting.

RESULTS

Bacterial DNA was detected in the peripheral blood of 62.0% of the patients with SAP. The expression of CPTP and tight junction proteins in SAP patients was lower than that in healthy controls. Among the patients with SAP, those positive for BT(+) showed a lower level of CPTP and occluding (OC) and zonula occludens-1 (ZO-1) expression and a higher level of IVA cPLA2 expression than BT(-) patients. Moreover, the expression of CPTP was significantly associated with ZO-1 and showed a negative correlation with expression of IVA cPLA2 in SAP-BT(+) patients.

CONCLUSIONS

CPTP affects the expression of tight junction proteins and may protects the intestinal epithelial barrier by downregulating the expression of IVA cPLA2.

[DIAGNOSTIC AND PROGNOSTIC UTILITY OF ENTERAL FAILURE IN PATIENTS WITH ACUTE NECROTIC PANCREATITIS]

Acute necrotic pancreatitis was followed by disorders of intestinal functions in 96.7% of patients and in 68% — its failure was occurred what had directly influenced on frequency of purulent—septic complication and mortality rate. It was proved that citrulline plasma level had been objectively reflected the severity of enteral failure and served as independent lethality criteria in patients with acute necrotic pancreatitis.

[Not Available]

Examination and treatment of 70 patients, suffering an acute necrotic pancreatitits, was conducted. Content of presepsin, procalcitonin, С—reactive protein and interleukin—6 (ІL—6) in the patients' blood plasma was determined, and bacteriological investiga' tions, contrast—enhanced CT were conducted as well. Positive results of bacteriologi' cal investigations were noted in 43 patients. Level of presepsin and procalcitonin in patients, suffering purulent—septic complications, in 3 — 4 times exceeded such in a sterile pancreonecrosis. Presersin level,exceeding over 632 pg/ml, have permitted to confirm the presence of local and systemic infection with high specificity and sensitivi' ty, and this have exceeded diagnostic possibilities of the procalcitonin content determi' nation. High level of ІL—6 and С—reactive protein is characteristic for the systemic inflammatory response syndrome (SIRS) of infective and noninfective origin.

Association of Matrix Metalloproteinases -7, -8 and -9 and TIMP -1 with Disease Severity in Acute Pancreatitis. A Cohort Study

Objectives

Several biomarkers for early detection of severe acute pancreatitis (SAP) have been presented. Matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP) are released early in inflammation. We aimed to assess levels of MMP-7, -8, -9 and TIMP-1 in acute pancreatitis (AP) and explore their ability to detect disease severity. Our second aim was to find an association between MMPs, TIMP and creatinine.

Methods

We collected plasma samples for MMP-7, -8, -9 and TIMP-1 analyses from 176 patients presenting within 96 h from onset of acute pancreatitis (AP) symptoms. We used samples from 32 control subjects as comparison. The revised Atlanta Classification was utilised to assess severity of disease. Receiver operating characteristic curve analysis and Spearman´s Rho-test were utilised for statistical calculations.

Results

Compared with controls, patients showed higher levels of all studied markers. MMP-8 was higher in moderately severe AP than in mild AP (p = 0.005) and MMP-8, -9 and TIMP-1 were higher in severe than in mild AP (p<0.001, p = 0.005 and p = 0.019). MMP-8 detected SAP with an AUC of 0.939 [95% CI 0.894–0.984], LR+ 9.03 [5.30–15.39]. MMP-8, -9 and TIMP-1 failed to discern moderately severe AP from SAP. MMP-7 was not different between patient groups. MMP-7 and TIMP-1 correlated weakly with creatinine (Rho = 0.221 and 0.243). MMP-8 might be a useful biomarker in early detection of SAP.

Perfusion-CT--Can We Predict Acute Pancreatitis Outcome within the First 24 Hours from the Onset of Symptoms?

PURPOSE

Severe acute pancreatitis (AP) is still a significant clinical problem which is associated with a highly mortality. The aim of this study was the evaluation of prognostic value of CT regional perfusion measurement performed on the first day of onset of symptoms of AP, in assessing the risk of developing severe form of acute pancreatitis.

MATERIAL AND METHODS

79 patients with clinical symptoms and biochemical criteria indicative of acute pancreatitis (acute upper abdominal pain, elevated levels of serum amylase and lipase) underwent perfusion CT within 24 hours after onset of symptoms. The follow-up examinations were performed after 4-6 days to detect progression of the disease. Perfusion parameters were compared in 41 people who developed severe form of AP (pancreatic and/or peripancreatic tissue necrosis) with parameters in 38 consecutive patients in whom course of AP was mild. Blood flow, blood volume, mean transit time and permeability surface area product were calculated in the three anatomic pancreatic subdivisions (head, body and tail). At the same time the patient's clinical status was assessed by APACHE II score and laboratory parameters such as CRP, serum lipase and amylase, AST, ALT, GGT, ALP and bilirubin were compared.

RESULTS

Statistical differences in the perfusion parameters between the group of patients with mild and severe AP were shown. Blood flow, blood volume and mean transit time were significantly lower and permeability surface area product was significantly higher in patients who develop severe acute pancreatitis and presence of pancreatic and/or peripancreatic necrosis due to pancreatic ischemia. There were no statistically significant differences between the two groups in terms of evaluated on admission severity of pancreatitis assessed using APACHE II score and laboratory tests.

CONCLUSIONS

CT perfusion is a very useful indicator for prediction and selection patients in early stages of acute pancreatitis who are at risk of developing pancreatic and/or peripancreatic necrosis already on the first day of the onset of symptoms and can be used for treatment planning and monitoring of therapy of acute pancreatitis. Early suspicion of possible pancreatic necrosis both on the basis of scores based on clinical status and laboratory tests have low predictive value.

[DIAGNOSTIC MARKERS AS PREDICTORS OF NECESSITY FOR THE OPERATIVE INTERVENTIONS PERFORMANCE IN PATIENTS FOR CORRECTION OF OXIDATIVE STRESS IN AN ACUTE PANCREATITIS]

In the investigation 70 patients were included, treated for necrotic acute pancreatitis. On the 7th day from an acute pancreatitis occurrence a state of oxidative system was studied in the patients. Raising of the blood serum concentration of malonic dialdehyde higher than 3.68 mcmol/l, reduction of the glutationperoxidase activity lower than 8.49 mcmol NADFН(2) h/mg protein and glutationreductase — lower than 5.18 mcmol NADFН(2) h/mg of protein before 7 days of treatment of an acute pancreatitis was accompanied by raising of the pancreas infectioning risk, what have had demanded the operative intervention performance.

[APPLICATION OF PRESEPSIN IN DIAGNOSIS AND TREATMENT OF PURULENT-SEPTIC COMPLICATIONS OF ACUTE NECROTIC PANCREATITIS]

In 70 patients, suffering an acute necrotic pancreatitis (ANP), and 10 practically healthy persons a content of presepsin in a blood plasm, using immunochemiluminescent method and conducted bacteriological investigations, were analyzed. The infection occurrence is accompanied by plausible upgrading of a presepsin level in a blood plasm, depending on activity and severity of a septic process: in local infection--up to (677 ± 30) pg/ml, sepsis--up to (988 ± 47) pg/ml, severe sepsis--up to 2668 pg/ml; in an ANP without infection it have constituted (332 ± 38) pg/mI at average, in practically healthy persons--(184 ± 16) pg/mI. A presepsin level correlates with a state severity in accordance to APACHE I scale, what permits to estimate the patients state severity objectively, to prognosticate a favorable and unfavorable consequences of treatment, rapidly changing, depending on efficacy of treatment.

Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis

OBJECTIVE

To develop a model for the early prediction of severe acute pancreatitis based on the revised Atlanta classification of acute pancreatitis.

METHODS

Clinical data of 1308 patients with acute pancreatitis (AP) were included in the retrospective study. A total of 603 patients who were admitted to the hospital within 36 hours of the onset of the disease were included at last according to the inclusion criteria. The clinical data were collected within 12 hours after admission. All the patients were classified as having mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) based on the revised Atlanta classification of acute pancreatitis. All the 603 patients were randomly divided into training group (402 cases) and test group (201 cases). Univariate and multiple regression analyses were used to identify the independent risk factors for the development of SAP in the training group. Then the prediction model was constructed using the decision tree method, and this model was applied to the test group to evaluate its validity.

RESULTS

The decision tree model was developed using creatinine, lactate dehydrogenase, and oxygenation index to predict SAP. The diagnostic sensitivity and specificity of SAP in the training group were 80.9% and 90.0%, respectively, and the sensitivity and specificity in the test group were 88.6% and 90.4%, respectively.

CONCLUSIONS

The decision tree model based on creatinine, lactate dehydrogenase, and oxygenation index is more likely to predict the occurrence of SAP.

[GENDER DIFFERENCES OF THE HEMOSTASIS POSTAGRESSIVE EARLY RESPONSE IN ACUTE NECROTIZING PANCREATITIS]

The study was performed in a group of 25 patients with acute necrotizing pancreatitis (mean age 46.2 ± 6.74 years). Gender differences of the hemostasis postagressive early response in the early stages of the disease were identified by comparing the procoagulant , anticoagulant and fibrinolytic blood activity of men and women suffering from pancreatitis. Compared to men, women showed higher concentrations of fibrinogen, D-dimer and VWF and smaller values marked trombokrit , antithrombin III, inhibitor of plasmin and protein C (p < 0.05). These results suggest a greater tendency to thrombi formation in women with acute pancreatitis; We believe that gender differences should be the subject of further research.

The predictive value of the prealbumin-to-fibrinogen ratio in patients with acute pancreatitis

OBJECTIVE

Early identification of severe acute pancreatitis (SAP) progression is important in acute pancreatitis (AP) treatment. The Ranson, APACHE II and CTSI systems are difficult to use and exhibit limited predictive value. Prealbumin and fibrinogen are acute phase reactants generally used to assess the nutritional statuses and coagulation functions of AP patients, respectively. Here, we explored the value of the combination of these two markers for evaluating AP severity and prognosis.

METHODS

One hundred and sixty-nine AP patients, including mild AP (MAP) (n = 101) and severe AP (SAP) patients (n = 68), were enrolled. Their Ranson, APACHE II and CTSI scores, routine laboratory test results, and prealbumin and fibrinogen levels were determined after admission. Multivariate regression analysis was performed to determine the independent predictors of AP severity. ROC curves were generated to determine the suitabilities of prealbumin and fibrinogen levels and the above-mentioned scores for SAP prediction.

RESULTS

The SAP patients exhibited higher scores, white blood cell counts, CRP and fibrinogen levels but lower calcium, prealbumin levels and prealbumin/fibrinogen ratio than the MAP patients (p < 0.05). The multivariate regression analysis demonstrated that the prealbumin/fibrinogen ratio was a good predictor of severity and outperformed CRP. The prealbumin/fibrinogen ratio was correlated with CRP, hospitalisation length and complication occurrence in SAP. The ROC curve analyses showed that the prealbumin/fibrinogen ratio exhibited superior sensitivity, specificity, PPV and NPV for SAP prediction over the scoring systems. With a cut-off of 31.70 mg/g, the sensitivity, specificity, PPV and NPV were 76.5%, 94.1%, 89.6% and 85.6%, respectively.

CONCLUSIONS

The prealbumin/fibrinogen ratio is a promising predictor of AP severity and prognosis.

Use of infliximab in treatment of acute pancreatitis

OBJECTIVE

The aim of this study was to investigating the effects of infliximab in severe necrotizing pancreatitis.

METHODS

Forty male Wistar rats were randomly divided into five groups evenly. Necrotizing pancreatitis was induced in group I and II by retrograde injection of 3% taurocholate into common pancreaticobiliary duct. In group III and IV saline was introduced instead of taurocholate to mimic pressure effect. Infliximab (8mg/kg) was infused through tail vein in group I and III and saline was infused in group II and IV just before laparotomy. Group V underwent sham laparotomy. Serum amylase activity, serum and tissue sialic acid, carbonyl content, malondialdehyde, total antioxidant activity (TAA) and pancreatic histopathology were assessed.

RESULTS

In group I serum sialic acid, malondialdehyde, carbonyl content and amylase activity were significantly lower than in group II (p<0.01). There were no significant differences for serum TAA between group I and II (p>0.05). Tissue sialic acid and malondialdehyde in group I were significantly lower than in group II (p<0.01). But tissue TAA in group I was significantly higher than in group II (p<0.01). Carbonyl content of group I was not significantly different from group II (p>0.05). Histopathologically, pancreatic sections of group II demonstrated extensive acinar and fat necrosis, hemorrhage, and inflammation. In group I Infliximab improved histopathological changes (p0.05).

CONCLUSION

Administration of infliximab resulted in a significant improvement in biochemical and histopathological alterations in acute necrotizing pancreatitis(Tab. 3, Ref. 43).

[CLINICAL AND LABORATORY FEATURES OF ACUTE PANCREATITIS BILIARY ETIOLOGY COURSE IN PATIENTS WITH DIABETES MELLITUS]

The dynamics of cytopathic hypoxia markers in patients with acute pancreatitis (AP) biliary etiology (BE), depending on the presence of concomitant diabetes mellitus (DM), which is an independent factor of premorbid severity increase and increase in the degree of operational and anesthetic risk. Markers of cytopathic hypoxia use as methods for early diagnosis of acute liver failure (ALF) and monitoring the effectiveness of its correction promising. In terms of cytopathic hypoxia may be at the stage of laboratory diagnostics to distinguish between destructive and non-destructive forms APBE, and for markers of endothelial dysfunction--destructive forms on the area and depth of destruction of the pancreas.

H2S mitigates severe acute pancreatitis through the PI3K/AKT-NF-κB pathway in vivo

AIM: To study the effect of hydrogen sulfide (H₂S) on severe acute pancreatitis (SAP) in a rat model.

METHODS: Sprague-Dawley (SD) rats were administered an intraperitoneal injection of saline containing 20% L-Arg (250 mg/100 g) hourly for over 2 h to induce SAP. The rats were treated with DL-propargylglycine (PAG, 50 mg/kg) or different dosages of NaHS (5 mg/kg, 10 mg/kg, 20 mg/kg or 100 mg/kg). PAG or NaHS was administered 1 h before induction of pancreatitis. Rats were sacrificed 24 h after the last L-Arg injection. Blood and pancreas tissues were collected.

RESULTS: The H₂S and cystathionine-γ-lyase mRNA levels in SAP rats were significantly lower than those in the control group, and treatment with PAG further reduced the H₂S level. Nevertheless, H₂S was significantly increased after NaHS administration compared with the SAP group, and the degree of upregulation was associated with the NaHS dosage. NaHS reduced the levels of plasma amylase, interleukin-6 and myeloperoxidase in pancreatic tissue. NaHS suppressed the degradation of IκBα and the activity of nuclear factor-κB, as well as the phosphorylation of PI₃K/AKT.

CONCLUSION: H₂S plays an anti-inflammatory role in SAP in vivo.

Arpin contributes to bacterial translocation and development of severe acute pancreatitis

AIM: To assess the impact of Arpin protein and tight junction (TJ) proteins in the intestinal mucosa on bacterial translocation in patients with severe acute pancreatitis (SAP).

METHODS: Fifty SAP patients were identified as study objects and then classified into two groups according to the presence of bacterial translocation (BT) in the blood [i.e., BT(+) and BT(-)]. Twenty healthy individuals were included in the control group. BT was analyzed by polymerase chain reaction, colonic mucosal tissue was obtained by endoscopy and the expression of TJ proteins and Arpin protein was determined using immunofluorescence and western blotting.

RESULTS: Bacterial DNA was detected in the peripheral blood of 62.0% of patients (31/50) with SAP. The expression of TJ proteins in SAP patients was lower than that in healthy controls. In contrast, Arpin protein expression in SAP patients was higher than in healthy controls (0.38 ± 0.19 vs 0.28 ± 0.16, P < 0.05). Among SAP patients, those positive for BT showed a higher level of claudin-2 expression (0.64 ± 0.27 vs 0.32 ± 0.21, P < 0.05) and a lower level of occludin (OC) (0.61 ± 0.28 vs 0.73 ± 0.32, P < 0.05) and zonula occludens-1 (0.42 ± 0.26 vs 0.58 ± 0.17, P = 0.038) expression in comparison with BT (-) patients. Moreover, the level of Arpin expression in BT (+) patients was higher than in BT (-) patients (0.61 ± 0.28 vs 0.31 ± 0.24, P < 0.05).

CONCLUSION: Arpin protein affects the expression of tight junction proteins and may have an impact on BT. These results contribute to a better understanding of the factors involved in bacterial translocation during acute pancreatitis.

Evaluating mean platelet volume as a new indicator for confirming the diagnosis of necrotizing pancreatitis

BACKGROUND

The aim of the present study is to discuss the possible role of mean platelet volume as a new predictor in the diagnosis of necrotizing pancreatitis.

METHODS

Study subjects are arranged in three different groups: Group I; control group (n= 40), Group II; acute pancreatitis (n= 40), Group III; necrotizing pancreatitis (n= 36). Demographic data and mean platelet volume values are recorded retrospectively.

RESULTS

Mean platelet volume of patients in Group II was 7.9±0.53, while in Group III patients it was 7.2±0.52 (p<0.001). When we compared the study groups with ROC analysis, results demonstrated that cut off value of necrotizing pancreatitis patients as 7,8 (area under curve: 0.857), sensitivity as 86.1% and specificity as 72.5%.

CONCLUSION

The current study shows that mean platelet volume in necrotizing pancreatitis patients is significantly reduced compared to that of patients in the control and acute pancreatitis group.

Beneficial effect of splanchnic nerve transection and harmful effect of vagotomy on acute necrotizing pancreatitis in the dog

BACKGROUND

The nervous system interacts dynamically with the immune system to modulate inflammation through humoral and neural pathways. However, the influence of visceral nerve (VN) on acute necrotizing pancreatitis (ANP) has drawn little attention.

AIM

To investigate the influence of VN on the pathophysiological process of ANP in dogs.

METHODS

The dogs were divided into a sham operation (SO) group, ANP group, ANP + vagal nerve trunk transection (VNTT) group, and ANP + greater splanchnic nerve transection (GSNT) group. The VNTT and GSNT groups underwent VNTT and GSNT respectively immediately after ANP induction. The levels of serum pancreatic amylase (AMY), calcium, high-sensitivity C-reactive protein (HCRP), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-10 (IL-10) were monitored dynamically and the pathological examinations of the pancreas was performed at postoperative day 7.

RESULTS

All serum parameters among the four groups showed no differences before the experiment (p > 0.05). At different postoperative times, the serum TNF-α, IL-1β, HCRP, and AMY were significantly increased, however, the serum calcium and IL-10 had dropped in the ANP group versus SO group (p < 0.05); an alike variation trend occurred between the VNTT group and ANP group (p < 0.05); an opposite variation trend occurred between the GSNT group and the ANP group (p < 0.05). The pancreas pathological scoring of VNTT group was highest in the four groups (p < 0.05) and GSNT group was lower versus ANP group (p < 0.05).

CONCLUSIONS

The GSNT has been shown to alleviate development of ANP, however, VNTT may exacerbate the ANP.

High plasma levels of the pro-inflammatory cytokine IL-22 and the anti-inflammatory cytokines IL-10 and IL-1ra in acute pancreatitis

BACKGROUND/OBJECTIVES

Pancreatic acinar cells are major targets of IL-22. Our aim is to study early plasma levels of IL-22, of pro- and anti-inflammatory cytokines in acute pancreatitis, and their association with severity or necrosis infection.

METHODS

Consecutive patients admitted to the Department of Hepato-Gastroenterology at Poitiers University of Medicine Hospital (France) with a diagnosis of AP were prospectively enrolled. Plasma concentrations of IL-22, IL-6, IL-8, IL-1 α, IL-1β, TNF- α, IFN-γ, IL-17A, IL-10, IL-1ra and IL-4 were assessed by multiple immunoassay at the admission time. A thoracoabdominal contrast-enhanced CT scan was performed at day 2.

RESULTS

Sixty-two patients were included; 13 patients (21%) had a severe acute pancreatitis, 5 patients (8%) developed necrosis infection and 29 patients (47%) had pleural effusion. Plasma levels of IL-22 were high in AP (135 ± 31 vs 4.2 ± 1.8 pg/ml for controls, p < 0.05), but did not correlate with the severity of the disease, whereas IL-6, IL-10 and IL-1ra where enhanced in patients with severe acute pancreatitis and with pleural effusion. Patients who further developed necrosis infection had higher levels of IL-1ra at admission (p = 0.0004).

CONCLUSION

In acute pancreatitis, high plasma levels of IL-22 are observed, regardless the severity of the disease. In contrast, severe forms were associated with increased levels of IL-6, IL-10 and IL-1ra. The beneficial or deleterious role of IL-22 in AP remains to be further studied.

Decreased serum platelet derived growth factor BB levels in acute and increased in chronic pancreatitis

AIM: To examine circulating growth factor concentrations in patients with acute pancreatitis (AP) and chronic pancreatitis (CP), and walled-off pancreatic necrosis (WOPN).

METHODS: Forty patients with mild AP, 40 patients with alcoholic CP, 33 patients with WOPN and 40 healthy subjects were examined. Serum concentrations of platelet derived growth factor BB (PDGF-BB), transforming growth factor β-1 (TGFβ-1), chemerin and high-mobility group box chromosomal protein 1 (HMBG1) were assayed by enzyme linked immunosorbent assay.

RESULTS: Patients with mild AP and those with WOPN had significantly lower serum levels of PDGF-BB compared to healthy subjects (4.0 ± 0.61 ng/mL vs 6.2 ± 0.76 ng/mL, P = 0.027, and 1.60 ± 0.31 ng/mL vs 6.2 ± 0.76 ng/mL, P < 0.001, respectively), while CP was associated with higher serum levels of PDGF-BB (12 ± 1.3 ng/mL vs 6.2 ± 0.76 ng/mL, P < 0.001). Circulating TGFβ-1 and chemerin levels were elevated in CP patients (57 ± 3.6 ng/mL vs 39 ± 3.6 ng/mL, P < 0.001 and 73 ± 7.2 ng/mL vs 48 ± 2.3 ng/mL, P < 0.001, respectively), but not in patients with AP and WOPN. No significant changes in serum HMBG1 levels were found either in patients with AP, WOPN or CP.

CONCLUSION: The serum levels of some growth factors and cytokines differ significantly in AP, WOPN and CP. These data suggest that selected growth factors and cytokines may be considered as potential diagnostic biomarkers in patients with pancreatic diseases.

[Alterations of lymphocyte subsets and indicators of immune suppression in patients with acute pancreatitis]

THE AIM OF STUDY

Assessment of changes in lymphocyte number and some indicators of the immune suppression (frequency of regulatory T cells (Treg), the level of expression of CTLA-4 (cytolytic T lymphocyte-associated antigen 4) and interleukin (IL)-10) in patients with acute pancreatitis (AP).

MATERIALS AND METHODS

Peripheral blood samples of 21 patients with AP (including 11 patients with pancreatic necrosis (PN)) were studied for analysis of lymphocyte subsets and 11 blood samples of healthy donors were estimated as control. Evaluation of the expression of molecules of lymphocytes was carried out by flow cytometry.

RESULTS

It was found that percentage of CD3+ T cells and their subpopulation of CD4+ T-helper cells in patients with AP were decreased as compared to the control group. Substantial changes were observed in patients with PN: together with decrease in the number of T cells, CD19+ B cells and CD4+ CD25+ activated T-helper cells were also reduced, and the percentage of CD8+ T cells was higher. The immunoregulatory index (CD4+/CD8+) was lower in the group of patients, than in control group. The frequency of Treg cells (CD4+ CD25hi and CD4+ CD25+ CD127lo) was higher in patients with AP than in the control. The expression level of the inhibitory molecule CTLA-4 in the subset of CD4+ CD25hi Treg cells in patients with AP was also increased. Moreover, it was found that the expression level of anti-inflammatory cytokine IL-10 was higher in T-helper cells from patients with AP.

CONCLUSION

Changes in cellular immunity (especially patients with PN) werefound in patients wish AP. These changes may indicate the possible development of secondary immunodeficiency. This is probably related to the generation of immune suppression, since the values of the investigated parameters (frequency of Treg cells, the expression of CTLA-4 and IL-10) in patients with AP were higher than in controls.

Therapeutic effect of human umbilical cord-derived mesenchymal stem cells in rat severe acute pancreatitis

AIM

To investigate the therapeutic effect of umbilical cord-derived mesenchymal stem cells (UC-MSCs) on rat severe acute pancreatitis (SAP).

METHODS

Rats were randomly divided into three groups (n = 15 per group): control group, SAP group, and SAP+MSCs group. SAP was established by retrograde pancreatic duct injection of 3% sodium taurocholate. In SAP+MSCs group, UC-MSCs at 1 × 10(7) cells/kg were injected via the tail vein 12 h after SAP. Rats (n = 5 per group) were sacrificed on days 1, 3 and 5, and the blood and pancreatic tissues were collected. The levels of serum amylase, lipase, inflammatory cytokines, and anti-inflammatory cytokines were determined. Pathological changes of the pancreas (HE staining) and apoptotic acinar cells (TUNEL staining) were observed under light microscope.

RESULTS

The levels of serum amylase and lipase in SAP group were significantly higher than those in control group (P<0.05). The pancreas in SAP group showed significantly massive edema, inflammation, hemorrhage and necrosis when compared with control group. There were numerous TUNEL-positive apoptotic acinar cells after SAP. However, in SAP+MSCs group, the levels of serum amylase were significantly reduced on days 1, 3, and 5 after MSC transplantation (P<0.01). The serum lipase level in SAP+MSCs group was significantly lower than that in SAP group on days 3 and 5 (P<0.01). The edema formation, inflammatory cell infiltration, hemorrhage, and necrosis were reduced significantly attenuated in SAP+MSCs group as compared to SAP group (P<0.05). MSCs significantly reduced the levels of pro-inflammatory cytokines (TNF-α, IL-1β, and IL-6), but increased the levels of anti-inflammatory cytokines (IL-4 and IL-10) in SAP rats. The number of TUNEL-positive acinar cells was significantly reduced on days 3 and 5 after MSCs transplantation (P<0.01).

CONCLUSION

Transplantation of UC-MSCs significantly inhibits inflammation and decreases pancreatic injury secondary to SAP.

Surveillance of intra-abdominal pressure and intestinal barrier function in a rat model of acute necrotizing pancreatitis and its potential early therapeutic window

OBJECTIVES

To monitor intra-abdominal pressure (IAP) and intestinal barrier function in a rat model of acute necrotizing pancreatitis (ANP) to elucidate a potential relevant therapeutic window.

METHODS

Sprague-Dawley rats were randomly divided into experimental or control groups. The ANP group (n = 40) was injected with 4.5% sodium taurocholate into the pancreatic duct to induce ANP. The controls received only abdominal opening surgery (sham-operated, SO; n = 40) or no treatment or surgery (baseline; 0 h, n = 20). The SO and ANP groups were then randomly subdivided into 3, 6, 12 and 24 h groups (n = 10 each). IAP was measured at each time point and the rats were sacrificed to measure the weight of accumulated ascites fluid and the amylase, endogenous creatinine (Cr), total bilirubin (TB), tumor necrosis factor- alpha (TNF-alpha), diamine oxidase (DAO), and D-lactate. Mortality and the development of pathological changes in the pancreas and intestines were also monitored.

RESULTS

IAP showed a continuous upward trend in the ANP group, with values 2 to 3 times higher than those in the SO group at the corresponding time points and the rising rate was peaking at 6 h. The levels of plasma amylase, TNF-alpha, Cr, TB, DAO, and D-lactate also gradually increased in the ANP group over time and were significantly higher than in the SO group at 3, 6, 12 and 24 h (all P<0.05). Moreover, the rising rate of TNF-alpha, DAO, and D-lactate also peaked at 6 h.

CONCLUSIONS

The ANP-induced changes in IAP, inflammatory factors and intestinal barrier that we observed in the rat model were especially obvious at 6 h post-induction, suggesting an early therapeutic window for the treatment of ANP in humans.

Focused open necrosectomy in necrotizing pancreatitis

BACKGROUND

The control of sepsis is the primary goal of surgical intervention in patients with infected necrosis. Simple surgical approaches that are easy to reproduce may improve outcomes when specialists in endoscopy are not available. The aim of the present study was to describe the experience with a focused open necrosectomy (FON) in patients with infected necrosis.

METHOD

A prospective pilot study conducted to compare a semi-open/closed drainage laparotomy and FON with the assistance of peri-operative ultrasound. The incidence of sepsis, dynamics of C-reactive protein (CRP), intensive care unit (ICU)/hospital stay, complication rate and mortality were compared and analysed.

RESULTS

From a total of 58 patients, 36 patients underwent a conventional open necrosectomy and 22 patients underwent FON. The latter method resulted in a faster resolution of sepsis and a significant decrease in mean CRP on Day 3 after FON, P = 0.001. Post-operative bleeding was in 1 versus 7 patients and the incidence of intestinal and pancreatic fistula was 2 versus 8 patients when comparing FON to the conventional approach. The median ICU stay was 11.6 versus 23 days and the hospital stay was significantly shorter, 57 versus 72 days, P = 0.024 when comparing FON versus the conventional group. One patient died in the FON group and seven patients died in the laparotomy group, P = 0.139.

DISCUSSION

FON can be an alternative method to conventional open necrosectomy in patients with infected necrosis and unresolved sepsis.

[Prognostication of acute-pancreatitis-associated pulmonary injury based on determination of cytokines levels]

The results of examination of 68 patients, admitted to hospital for an acute pancreatitis during 48 h from its occurrence, were analyzed. In all the patients the cytokines (IL-8, IL-10, TNF-alpha) content was determined in the blood, using immunoenzymal analysis. Algorithm of prognostication of an acute pancreatitis-associated pulmonary injury, basing on determination of the cytokines contents, was elaborated.

Plasma endothelin-1 levels in pancreatic inflammations

BACKGROUND

In inflammatory processes endothelin exerts an important effect on the pancreatic blood vessels and disturbances in pancreatic microcirculation.

OBJECTIVES

The aim of the study was to evaluate the usefulness of plasma endothelin-1 (ET-1) levels in determining the severity of pancreatitis, its prognosis and monitoring the course of therapy.

MATERIAL AND METHODS

The investigations were carried out on 115 subjects: 85 patients with pancreatitis and 30 persons serving as a control group. All the participants' ET-1 levels were determined by means of an enzymoimmunological test (Endothelin ETA Kit, Catalog No:583151, Cayman Chemical Company, Michigan, USA) on the 1st, 3rd, 5th and 7th days of treatment. In the control group, the mean ET-1 level was 1.37 pg/ml.

RESULTS

Acute pancreatitis (AP) was diagnosed in 53 patients, including 36 patients (67.9%) with severe AP. Their Ranson's scores were over 3 points. The highest mean plasma ET-1 levels were observed in 10 patients with severe AP with necrosis (6.37 +/- 1.9pg/ml). (5 to 9 points on Ranson's scale). In 26 patients with severe AP without necrosis, the mean plasma ET-1 level was 3.49 +/- 1.24 pg/ml. In 17 patients with mild AP the mean plasma ET-1 level was 3.48 +/-1.16 pg/ml (3 to 4 points on Ranson's scale). ET-1 levels normalized gradually with successful treatment. An increase in ET-1 levels between the 5th and 7th days was an unfavorable prognostic factor that was observed in all the patients who died.

CONCLUSIONS

Measuring plasma ET-1 levels permits early determination of cases with severe AP. ET-1 can be used as a marker for both the progress of the disease and the efficacy of the treatment. An increase in plasma ET-1 level between the 5th and 7th days of treatment may indicate irreversible ischemic lesions in the pancreas and the development of necrotic lesions.

[The comparative characteristic of coefficients of endogenic intoxication under severe acute pancreatitis]

The sample included 43 patients with severe acute pancreatitis. Two coefficients of endogenic intoxication were applied: Kei1 = (AMP/ECA)x 100, AMP -average molecular peptides, ECA--effective concentration of albumin and Kei2 = (Kplp/aos/ECA) x 100, PLP--products of lipid peroxidation, AOS--indicators of antioxidant system. ECA--effective concentration of albumin. The comparative characteristic of both coefficients is given. It is established that Kei2 provides more informative indicators of endogenic intoxication in patients died at third day after operation. The study proved that both Kei can be applied for evaluation of endogenic intoxication and prognosis of generalized pancreonecrosis depending on resources of laboratory service.

[Effect of apparatus plasmapheresis on the bowel barrier and motility function in patients with acute necrotizing pancreatitis]

Influence of therapeutic plasmapheresis on bowel barrier function and evacuation was investigated in 83 patients with severe acute necrotizing pancreatitis. Except standard therapy patient obtained therapeutic plasmapheresis using "Haemonetics" PCS 2 system. Complex treatment of patients with acute necrotizing pancreatitis and dynamic ileus using plasmapheresis increases contractive and propulsive function of stomach and duodenum and prolongs period of activity of these organs on 32%. Intestinal barrier function associates with restoration of bowel evacuation. Addition of plasmapheresis to standard therapy of necrotizing pancreatitis can be effective prevention of dynamic ileus.

[The indices dynamics of platelet pool and the level of TGF-beta1 in different forms of acute pancreatitis]

The results of study of quantitative functional characteristics of platelets are shown in patients with acute pancreatitis. The patients (57 people) with acute pancreatitis were examined: 40 patients had a mild clinical course of acute pancreatitis and 40 patients had a severe clinical course of acute pancreatitis. The circular functional mass of platelets and the level of TGF-beta1 were determined in dynamics in patients with acute destructive pancreatitis. A correlated analysis was made among the results obtained by means of laboratory and instrumental examinations and clinical course of acute pancreatitis. It was found, that the increase of TGF-beta1 and circular functional mass of platelets in the course of several days was really a good prognostic factor of clinical course of acute pancreatitis. The data obtained showed that the changes of indices of quantitative and functional characteristics of platelets are the important pathogenetic criterion of prognosis for severity of clinical course of acute pancreatitis.

Clinico-pathological particularities of the shock-related pancreatitis

Acute pancreatitis can develop in patients with shock due to the underlying diseases, surgical interventions or because of severe hypoperfusion. The aim of our work was to study the histological alterations of the pancreas in patients dying after cardiogenic, hypovolemic or septic shock, to demonstrate the presence and severity of pancreatic injury. We performed a retrospective study which included patients who died and who were autopsied after different types of shock, hospitalized between 2007-2009 in general and cardiac intensive care units. We excluded the patients with known pancreatic diseases. From 223 patients included in our study 39 presented necrotising hemorrhagic alteration of the pancreatic tissue. There were no differences in histological and immunohistochemical findings between the different etiopathogenetic types of shock. None of the patients had characteristic clinical signs for acute pancreatitis. The digestive symptoms, they presented, could be related to the underlying disease or to postoperative state. The common findings in these patients were prolonged and severe hypotension, associated renal dysfunction, leucocytosis, hyperglycemia and hypocalcemia. Pancreatitis can occur in patients with shock, due to prolonged hypoperfusion of the pancreas. It is difficult to diagnose it because clinical signs are altered due to severity of underlying disease or analgo-sedation commonly used in intensive care. We therefore recommend in patients with shock to consider the possible development of ischemic pancreatitis for prompt and efficient treatment.

[The characteristics of cell and humoral immunity in patients with acute pancreatitis under impact of cold laser radiation]

The analysis of immune status of 57 patients with acute pancreatitis made it possible to assess the impact of cold laser radiation on cell and humoral immunity under different forms of acute destructive pancreatitis. The sessions of laser therapy applied to patients with acute edematous pancreatitis favored the normalization of leucocytes indices, regeneration of lymphocytes. The leucocyte-T-lymphocyte index came to normality which is an indicator of adequacy of immune response.

Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a systemic disease with a rising incidence. Cardiac dysfunction may occur as an early complication of AP. B type natriuretic factor (BNP) is a diagnostic and prognostic indicator of cardiac disorders. Therefore, in this study we aimed to assess the relationship between serum BNP concentrations and severity of AP.

METHODS

Patients with AP who were admitted to gastroenterology clinic of our center, were included in this study. BNP measurements were performed twice, once on admission to the hospital and another after clinical and laboratory remission of the disease. All patients underwent echocardiography, abdominal ultrasonography and/or computed tomography chest X-ray and routine biochemical assays. Disease severity was determined by Ranson, Balthazar and Glasgow scoring systems.

RESULTS

A total of 55 patients with AP (33 male, 60%) were enrolled in the study. Causes of AP were biliary in 32 patients (58%), alcoholic in 10 (18%), idiopathic in 8 (15%), hyperlipidemic in 4 (7%) and ERCP related in one patient (2%), respectively. Serum BNP levels in first 2 days of admission and after the clinical and laboratory remission of disease were 444 ± 295.9 and 124 ± 109.5 pg/ml, respectively (p<0.001). Increased serum BNP levels were positively correlated with severity of the disease (p<0.001). We could not find a difference between serum BNPe levels of edematous and necrotizing patients (P = 0.683).

CONCLUSION

Increased serum BNP levels might be a plausible indicator of severity of AP during the course of the disease.

[Some of criteria in the evaluation of severity and prognosis with different forms of acute pancreatitis]

The aim of the research is to improve diagnosis and assessment of severity and prognosis with different forms of acute pancreatitis. In 79 patients were studied levels of leukocytes, lymphocytes, leucocyte intoxication index (LII), the content of lactate dehydrogenase (LDG), creatinephosphokinase (CPK), amylase, aspartate aminotransferase (AST, alanine aminotransferase (ALT).

RESULTS

The level of leukocytes reflects the severity of the disease, but had no prognostic value. The level of lymphocytes, LII. LDG and lipase reflect the severity, of the disease and have prognostic value. The level of amylase, AST, ALT, CPK not always reflect the severity of the disease, but had prognostic value.

CONCLUSION

The most readily available to assess the severity and prognosis in acute pancreatitis are the level of blood lymphocytes and LII. Indicators LDG. CPK, amylase, lipase, AST and ALT also reflect the course and prognosis of the disease.

[Influence of reamberin on the photohemotherapy of endogenous intoxication caused by acute experimental pancreatitis]

Combined application of photohemotherapy and antihypoxant reamberin for the treatment of endogenous intoxication favors fast (within one day) restoration of the functional condition of lungs and prevents the development of respiratory distress syndrome. High efficiency of the combined therapy is related to a fast stabilization of membranes, which is determined by the ability to correct lipid metabolism in lung tissues.

[A role of D-dimer and fibrinopeptide A in diagnosis of a hemostasis system disorders]

The investigations, concerning detection of the hemostasis system activation, were done in 26 patients, suffering various critical morbid states (an acute pancreatitis). The contents of products of the enzymes lysis of coagulation system and fibrinolytic system constitute one of the most precise indices. Fibrinopeptid A (FpA) is considered one of the most secure indices, confirming intravascular thrombin formation, and D-dimer--of a fibrin formation. In the patients examined a trustworthy increase of a D-dimer and FpA contents was registered, witnessing the hemostasis system activation in an acute pancreatitis as well as an excessive formation and lysis of fibrin. D-dimer and FpA contents in a plasma constitutes an important diagnostic index, its determination secures the possibility of early diagnosis and control of a hemostasis system disorders.

[Effects of combined enteral nutrition support on hemorrheologic parameters and the level of inflammatory factors in rabbits with severe acute pancreatitis]

OBJECTIVE

To explore the effects of combined enteral nutrition (CEN) on the hemorheologic parameters and the changing levels of inflammatory factors in an animal model of severe acute pancreatitis (SAP).

METHODS

The experimental animals were divided randomly into 3 groups, i.e. early enteral nutrition (EEN) group, CEN group and parenteral nutrition(PN)group (n = 20 each). Enteral nutrition was administered to the EEN and CEN group animals at 24 h and 72 h post-modeling respectively. The PN group animals were supported by parenteral nutrition all time. Hemorrheologic indices of all experimental animals were examined on Days 1, 3 and 7 post-modeling. And the inflammatory factors were examined on Days 1 and 7.

RESULTS

Compared with the EEN and PN groups, some hemorrheologic indices of the CEN group decreased significantly (P < 0.05) on Day 7 post-modeling. They included blood sedimentation, hematocrit (HCT), whole blood high-cut reduction viscosity and whole blood low-cut reduction viscosity. As compared within the CEN group, each hemorrheologic index was lower on Day 7 than that on Day 1 (P < 0.05). Except for whole blood high-cut reduction viscosity and erythrocyte aggregation index in the EEN group after a 7-day nutrition support, there was no significant change for all hemorrheologic indices in the PN group. As to the level of inflammatory factors, the values of interleukin 8 (IL-8) and tumor necrosis factor-α (TNF-α) in the CEN group were lower than those in the PN group on Day 7 post-modeling (P < 0.05). The values of IL-8 and IL-6 in the CEN group were lower than those in the EEN group on the same day (P < 0.05). As compared within the CEN group, the values of IL-6 and TNF-α were lower on Day 7 than those on Day 1 post-modeling (P < 0.05).

CONCLUSION

The modulatory mechanism of EN over SAP should be achieved by correcting hemorrheologic index change and lowering the level of inflammatory factors. A proper timing of EN is probably the most optimal nutrition support mode of SAP therapy.

[Study of changes in the system of the blood neutrophils in acute pancreatitis]

The changes in a system of the blood neutrophils in 65 patients, suffering different forms of an acute pancreatitis, were studied. The trustworthy differences in a neutrophils system structure were determined in patients while their effective conservative treatment, effective surgical treatment, complicated course of postoperative period and exitus lethalis. This data permit to adjust a base for algorithm creation on prognostication, diagnosis and monitoring in patients, suffering an acute pancreatitis.

[The systemic inflammatory response syndrome correction in acute destructive pancreatitis]

Acute pancreatitis is a disease of variable severity. In which some patients experience mild, self-limited attacks while others manifest a severe, highly morbid, and frequently lethal attack. The exact mechanisms by which diverse etiological factors induce an attack are still unclear. Recent studies have established the role played by inflammatory mediators in the pathogenesis of acute pancreatitis. In our research we have estimated influence of not steroid anti-inflammatory preparation on synthesis pro-and anti-inflammatory Cytokines at healthy donors and at patients with Acute pancreatitis.

[Clinical characteristics of children with acute pancreatitis]

OBJECTIVE

To analyze the characteristics of children with acute pancreatitis and provide the basis of early diagnosis and treatment.

METHODS

Totally 121 children with acute pancreatitis admitted to Hunan Children's Hospital between March 2003 and December 2009 were enrolled in this retrospective study. The data of clinical manifestations, biochemical examinations, imaging and prognosis were summarized and statistically analyzed.

RESULTS

Of the 121 cases, preschool and school-age children were the main groups, and the prevalent months were May and June. Abdominal pain (88.4%) and vomiting (61.2%) were the major initial symptoms of pancreatitis in children, but none of children under the age 1 year complained of abdominal pain; 70.2% had signs of abdominal tenderness, accompanied by abdominal rigidity, distension, hepatomegaly, jaundice, etc. Severe patients developed shock, convulsions, coma and so on. Serum amylase concentration increased to above the upper reference limit in 114 children (94.2%) when they admitted within 24 hours after admission. Urine amylase elevation was noted in 77 children (79.4%). The amylase concentration decreased after 3 days, but not all returned to normal 14 days afterward. Children with sustained serum amylase elevation or serum amylase level ≥ 3 times upper limit of normal range more likely to have fever, vomiting, abdominal distension, and pancreatic abnormalities at ultrasonography or CT which showed that the echo of pancreas decreased or enhanced, pancreas edema, pancreatic duct expanded, etc. Abdominal ultrasonography and CT showed that 75 cases (62.0%) had other organ damage besides pancreatitis, liver (25.3%) and intestinal (16.0%) damages were very common, while liver and myocardial damages were seen frequently in the laboratory examinations, which complicated with serum ALT/AST, total bilirubin, blood glucose elevation and myocardial enzyme abnormalities. Several gastroscopic examinations showed mucosal hyperemia and edema, sheet-like erosion, etc. Except for one case who underwent laparotomy, all the remaining children were treated with non-operative comprehensive treatment. Of them 119 were cured or improved, 2 died and 5 had recurred disease later.

CONCLUSIONS

Gastrointestinal symptoms were the main clinical manifestations of acute pancreatitis in children, often complicated with extrapancreatic damage. The younger the patient was, the less complaint of abdominal pain they had. This indicates that acute pancreatitis should be considered when children suffered from acute abdominal pain and vomiting which had no known cause or could not be explained. It is important to do take serial monitoring of serum amylase, and imaging procedures.

[Prognosis of the disease severity in patients with acute pancreatitis]

Estimation of the severity state in patient, suffering an acute pancreatitis, while admitting him into a hospital, constitutes a significant part of diagnosis and complex treatment. Application of a highly accurate scales and markers, which are used to prognosticate the disease course severity and to determine the inflammation grade, may influence the results of complex treatment of the patients. In the investigation a high diagnostic accuracy in prognosis of an acute pancreatitis course severity was noted for APACHE II scale (24 hours) and Ranson scale (48 hours). There was established, that determination of a C-reactive protein content has less diagnostic accuracy, but it may be applied as a less complex and more rapid test for prognostication of an acute pancreatitis course severity after admitting the patient to hospital.

[Effect of liquid resuscitation on homeostasis of patients with severe acute pancreatitis]

OBJECTIVE

To evaluate the effect of liquid resuscitation on acid-base balance and electrolytes of patients with severe acute pancreatitis (SAP).

METHODS

According to the target of liquid resuscitation, 22 patients with SAP involved in this self-controlled prospective study received sufficient liquid resuscitation in acute stage of acute pancreatitis. The results of blood gas analysis, acid-base balance and electrolytes were compared before and after liquid resuscitation. The correlation between the volume of liquid used in resuscitation and the level of blood chlorine was analyzed.

RESULTS

The mean resuscitation duration was (15.0±2.4) hours, and the volume of liquid resuscitation was 3 4594 203 ml, with mean volume (3 910± 102) ml in 22 patients; blood sodium (mmol/L) and chlorine (mmol/L) levels were both significantly higher after resuscitation compared with those before resuscitation (Na(+): 145.83±1.85 vs. 139.67±2.25, Cl(-): 117.33±1.64 vs. 101.83±1.77, both P<0.05). Blood pH value, hematocrit (Hct), anion gap (AG, mmol/L), blood lactic acid (mmol/L) were slightly lowered after resuscitation (pH value: 7.39±0.02 vs. 7.42±0.02, Hct: 35.63±1.58 vs. 46.85±2.38, AG: 8.02±1.21 vs. 14.47±0.89, blood lactic acid: 1.10±0.18 vs. 1.97±0.15, P<0.05 or P <0.01). In addition, the level of blood chlorine was significantly correlated with the volume of liquid used in resuscitation (r=0.720 8,P<0.01).

CONCLUSION

The target of liquid resuscitation in patients with SAP should be cautiously determined, including control of the volume of liquid for resuscitation, in order to avoid acid-base imbalance or hyperchloraemia. At the same time, the change in internal environment should be monitored.