Acute Peripancreatic Fluid Collection Research Articles

The relationship between inflammatory cytokines and in-hospital complications of acute pancreatitis.

Acute necrotic collection (ANC), acute peripancreatic fluid collection (APFC), pleural effusion, and ascites are common early complications of acute pancreatitis. This study aimed to investigate the relationship between 12 serum cytokines and the early complications and severity of acute pancreatitis (AP). We retrospectively analyzed the clinical data of 307 patients with AP, and divided them into severe group and mild-to-moderate group according to the revised Atlanta classification. Propensity score matching was used to control for confounding factors. Binary logistic regression analysis was used to explore the relationship between cytokine levels and early complications of AP. Serum levels of interleukin (IL)-1β, IL-5, IL-6, IL-8, IL-10, IL-17, and tumor necrosis factor-α were significantly higher in the severe acute pancreatitis (SAP) group than in the non-SAP group (p < .05). After adjusting for confounding factors, the upper quartiles of IL-6, IL-8, and IL-10 were associated with an increased risk of ANC compared with those in the lowest quartile (IL-6: quartile 3, odds ratio [OR] = 3.99, 95% confidence interval [CI] = 1.95-8.16; IL-8: quartile 4, OR = 2.47, 95% CI = 1.27-4.84; IL-10: quartile 2, OR = 2.22, 95% CI = 1.09-4.56). APFC was associated with high serum levels of IL-6 (quartile 3, OR = 1.32, 95% CI = 1.02-1.72), pleural effusions were associated with high serum levels of IL-1β, IL-6, IL-8, and IL-10 (IL-1β: quartile 4, OR = 2.36, 95% CI = 1.21-4.58; IL-6: quartile 3, OR = 4.67, 95% CI = 2.27-9.61; IL-8: quartile 3, OR = 2.95, 95% CI = 1.51-5.79; IL-10: quartile 4, OR = 3.20, 95% CI = 1.61-6.36), and high serum levels of IL-6 and IL-10 were associated with an increased risk of ascites (IL-6: quartile 3, OR = 3.01, 95% CI = 1.42-6.37; IL-10: quartile 3, OR = 2.57, 95% CI = 1.23-5.37). Serum cytokine levels, including IL-1β, IL-6, IL-8, and IL-10 may be associated with the occurrence of early complications of AP. In daily clinical practice, IL-6 may be the most worthwhile cytokine to be detected.

Risk Factors Associated With the Development of Acute Peripancreatic Fluid Collections on Follow-Up Imaging After Acute Pancreatitis: What Physicians Need to Know

Risk Factors Associated With the Development of Acute Peripancreatic Fluid Collections on Follow-Up Imaging After Acute Pancreatitis: What Physicians Need to Know

Endosonography in the diagnosis and treatment of acute peripancreatic fluid collections

Endosonography in the diagnosis and treatment of acute peripancreatic fluid collections

Relation between triglycerides and the severity of acute pancreatitis combined with nonalcoholic fatty liver disease: a retrospective study

BackgroundNonalcoholic fatty liver disease (NAFLD) can exacerbate the severity of acute pancreatitis (AP), and this severity is worsened with increased severity of NAFLD. This study aimed to investigate the relation between serum triglyceride (TG) and the severity of AP with NAFLD by collecting clinical data from AP patients with NAFLD.MethodsAP patients with NAFLD were divided into 2 groups according to TG levels: hypertriglyceridemia (HTG) group and non-hypertriglyceridemia (NHTG) group.ResultsIn total, 598 AP patients with NAFLD were enrolled in this study, including 433 in the HTG group and 165 in the NHTG group. Compared with the NHTG group, AP patients in the HTG group were more serious (P < 0.05). The incidence of persistent organ failure (POF), especially persistent respiratory failure, and the ratio of acute peripancreatic fluid collection (APFC) were higher in the HTG group (P < 0.05). Higher TG levels were associated with a higher incidence of APFC (P < 0.05). Logistic regression analysis showed that the risk of APFC was significantly higher in moderate and severe NAFLD than in mild NAFLD.ConclusionHTG may aggravate the severity and local complications of AP combined with NAFLD.

急性膵炎後の被包化壊死増大に伴い脾梗塞・胃壁虚血に陥り外科手術を要した1例(Acute pancreatitis and enlarged area of walled–off necrosis followed by infarction of the spleen and ischemia of the gastric wall requiring surgery: case report)

症例は40歳の男性。基礎疾患に高トリグリセリド血症があり，急性膵炎を繰り返していた。約9か月前に壊死性膵炎を発症して膵尾部と胃脾間，結腸間膜に被包化壊死を合併，以降定期的にCT画像検査による経過観察を行っていた。今回左側腹部痛を主訴に来院し，腹部CT検査において胃脾間，膵尾部に各々44mm，43mmの被包化壊死を認め，いずれも2か月前の検査時より被包化壊死の増大を認めた。またそれぞれの被包化壊死に隣接して胃穹窿部の浮腫性変化と脾動脈閉塞，脾梗塞を認めた。ヘパリン・抗菌薬・鎮痛薬による保存的治療から開始したが，発熱が継続し，炎症反応の改善も得られず，入院第4病日のCT検査では脾梗塞の状況に改善がなく，一方で被包化壊死に接する胃壁全層の虚血所見が明らかとなったため，保存的治療を断念し，緊急開腹術での膵尾部切除・脾摘出・胃部分切除術を施行した。病理所見では被包化壊死と脾動脈との間には炎症性細胞の浸潤を認め，脾動脈内腔には白色血栓を認めた。胃壁漿膜側は被包化壊死に伴う炎症所見や周囲血管内の血栓形成を認めた。被包化壊死の自然史は明確ではなく，保存的治療においては，症状や画像所見を丁寧に評価して外科的治療介入の時期を見逃さないことが重要である。 A 40–year–old male with hypertriglyceridemia and recurrent acute pancreatitis was undergoing regular imaging to monitor walled–off necrosis (WON) that had developed 9 months earlier secondary to necrotic pancreatitis. The patient presented with acute left abdominal pain. Abdominal CT showed WON by the gastrosplenic ligament (44mm) and in the pancreatic tail (43mm). Both areas grew since the last imaging 2 months earlier. Edematous changes in the fornix, splenic artery occlusion, and splenic infarction were observed adjacent to areas of WON. Despite conservative management, fever and elevated inflammatory biomarkers persisted. CT after admission showed no change in the splenic infarction. It also detected ischemia in all layers of the gastric wall adjacent to areas of WON. Emergency laparotomy was performed for pancreatic tail resection, splenectomy, and partial gastric resection. Pathologic examination showed infiltration of inflammatory cells between the areas of WON and the splenic artery and a white thrombus in the splenic artery lumen. There was inflammation and thrombus in the blood vessels surrounding areas of WON on the serosal side of the gastric wall. Although the natural history of WON is not well studied, careful evaluation of clinical findings and imaging for timely surgical intervention is required. 2012年の改訂アトランタ分類 1により膵炎の局所合併症としてみられる膵あるいは膵周囲の液体貯留は，壊死の有無と発症からの経過時間により，間質性浮腫性膵炎後に発症する急性膵周囲液体貯留（acute peripancreatic fluid collection: APFC）と壊死性膵炎後に発症する急性壊死性貯留（acute necrotic collection: ANC），それぞれが4週以上経過した膵仮性嚢胞（pancreatic pseudocyst: PPC）と被包化壊死（walled–off necrosis: WON）の4つのカテゴリーに分類された。ガイドライン 2, 3, 4ではこれら膵局所合併症に関して無症候性，非感染性のものについては保存的加療を推奨し，症候性，感染合併症例を治療適応としている。今回我々は，繰り返す急性膵炎後にWONを発症し，その経過観察中に合併した脾動脈本幹閉塞による脾梗塞と，胃後壁への炎症波及に伴う胃壁虚血に対して外科的治療を施行した1例を経験した。これまでに急性膵炎に伴う脾梗塞の発生率は約7%と報告され 5，また急性膵炎に伴い胃壁梗塞および脾梗塞を合併した報告例はある 6が，WONの自然経過における同合併症の発生に関しては明確にされていない。我々は自験例におけるWONの経時的画像所見と術中所見および切除標本の病理学的所見からその機序と治療方針について考察した。 本論文は倫理委員会の承諾を必要としない症例報告である。また，個人情報保護法に基づいて匿名化がなされており，患者本人から論文出版に関する同意を取得している。 患 者：40歳の男性 主 訴：左側腹部痛 基礎疾患：高トリグリセリド血症（LPL遺伝子異常症疑い） 生活歴：喫煙歴なし，飲酒習慣なし 現病歴：以前より急性膵炎を繰り返していた。9か月前に壊死性膵炎を罹患以降，膵尾部と胃脾間，結腸間膜にWONが形成されていた（Fig. 1a–c）。6か月前，4か月前には浮腫性膵炎を罹患し絶食，輸液，ガベキサートメシル酸塩点滴，抗菌薬，経管栄養による保存的治療を受けていた。今回来院約12時間前に突然左側腹部痛を自覚，改善を認めないため，ウォークインで救急外来を受診した。 Abdominal computed tomography (CT) with contrast (a–e: contrast–enhanced CT, delayed phase, f: contrast–enhanced CT, arterial phase). a: 9 months before admission, at the onset of WON, a solitary lesion was found in the pancreatic tail. b: 6 months before admission, cystic lesions were found in the pancreatic tail and by the gastrosplenic ligament. There was no abnormal contrast effect on the spleen. c: 4 months before admission, cystic lesions were found in the pancreatic tail and by the gastrosplenic ligament. There was no abnormal contrast effect on the spleen. d: Edematous changes in the fornix of the stomach adjacent to WON on arrival (white arrow). e: All layers of the gastric wall were poorly enhanced on day 4 of admission (black arrow). f: On CT scan at the time of admission, the splenic artery next to WON in the pancreatic tail had a contrast defect (white and black arrowheads). d–f: There was poor contrast enhancement of the spleen. 経 過：来院時のバイタルサインは意識清明，心拍数91/分，血圧169/109mmHg，呼吸数24/分，酸素飽和度97%（室内気），体温37.1℃であった。身体診察では，腹部は平坦，左側を中心に腹部全体の圧痛，筋性防御を認めた。血液検査では，白血球18,100/µL，CRP 12.15mg/dLと非特異的炎症反応上昇を認め，Fib 536mg/dL，D–dimer 1.29µg/mLと軽度の線溶系亢進を認めた。膵酵素の上昇は認めなかった（Table 1）。腹部造影CT検査（Fig. 1d）では，胃脾間に最大径44mm（前回2か月前撮影時41mm），膵尾部に最大径43mm（前回2か月前撮影時38mm）のWONを認め，膵尾部以遠の脾動脈造影欠損，脾全体の造影不良を認めた（Fig. 1f）。またWONに接した胃穹窿部壁の造影不良を認めたが（Fig. 1d白矢印），胃周囲の血管には造影欠損を認めず，胃壁の浮腫性変化と考えた。脾梗塞の診断で入院加療とし，抗菌薬，ヘパリン15,000単位/日点滴静注，疼痛管理を開始した。入院後痛みは軽減したが，発熱の持続と第3病日の血液検査では白血球17,900/µL，CRP 31.40mg/dLと炎症反応の改善を得られず，入院第4病日に腹部造影CT検査を再検したところ，胃穹隆部の壁全層に及ぶ造影欠損が明確となった（Fig. 1e黒矢印）。上部消化管内視鏡検査を施行したところ，噴門部大弯から後壁にかけて胃粘膜の虚血性変化を認めた（Fig. 2）。比較的広範囲で胃壁全層の虚血壊死が生じていると疑われたため治療方針を改め，同日，緊急開腹手術を行った。腹腔内には漿液性腹水を少量認め，大網切開し網嚢腔を開放すると胃脾間・膵尾部のWONは胃後壁・膵尾部と強固に癒着一塊となっていた。脾動脈への前面からのアプローチは炎症波及により剥離困難であったため膵脾脱転したうえで脾動脈を根部から約1cmの部位で結紮し，膵臓も同部位で切離，合わせて梗塞に陥った脾を摘出した。胃後壁はWON癒着部から1cmほど離れた部位で胃壁を貫通し，壊死した胃粘膜を視認しつつWONを含めた胃部分切除を行った。結果的に胃穹窿部から体部後壁までを切除した（手術時間3時間39分，術中出血量470mL）。病理所見では胃後壁・WON・膵尾部・脾臓は一塊となり（Fig. 3a），線維性肉芽組織からなるWONの嚢胞壁には好中球浸潤を伴う中等度の急性炎症がみられ，内部は壊死物質で満たされていた。胃壁は固有筋層に及ぶ潰瘍形成を認め，一部で胃壁全層に及ぶ凝固壊死，浮腫，高度の急性炎症を認めた。漿膜側にはWONに伴う炎症所見とともに周囲の動脈内に血栓形成を認めた（Fig. 3b）。胃壁の明らかな穿孔は認めなかった。WONと隣接する動脈との間には炎症性細胞の浸潤を認め，脾動脈内腔は白色血栓で閉塞（Fig. 3c），脾臓は凝固壊死に陥っていた。術後経過は良好で，術後4日目に経口摂取を開始，同11日目に退院した。 Upper gastrointestinal endoscopy findings. There was ischemia of the gastric mucosa from the cardia and greater curvature to the posterior wall. Macroscopic and microscopic (×20) surgical pathology findings. a: Macroscopic cystic lesions were partially solid. (b, c) Histologically, the wall of the cystic lesion consists of fibrous granulation tissue with no epithelium, acute inflammation with infiltration by neutrophils, and contained internal necrotic tissue. b: The gastric wall had ulcer formation extending to the muscularis propria, coagulative necrosis throughout all layers, edema, and severe acute inflammation. Inflammatory infiltrates and thrombus were observed in the blood vessels surrounding WON on the serosal side of the gastric wall. c: In the pancreas, there was severe fibrosis, edema, and moderate to severe acute and chronic inflammation. A white thrombus was observed in the lumen of the splenic artery. W: walled–off necrosis (WON), P: pancreas, St: stomach, Sp: spleen 急性膵炎における壊死性膵炎の発症率は10～20%とされ 7，WONは壊死性膵炎の晩期合併症として生じる。WONは膵実質および膵周囲脂肪組織の壊死部が時間とともに当初の固形から融解壊死により液状化し，周囲を肉芽性・繊維性皮膜で覆う状態になったものである。近年までWONと間質性浮腫性膵炎の晩期合併症であるPPCは明確には区別されておらず，両者を含めた検討において，経過観察症例の30～50%で重大な偶発症・合併症が発生したと報告され 8, 9，発生6週以降では自然消退は期待できず偶発症・合併症率が高いとする報告 10や，嚢胞径が6cmを超えるものでは自然消退の可能性が低下し偶発症・合併症率が高くなるとする報告 9がある。一方でManraiら 11は壊死性膵炎153名の観察研究において，143名がANCを合併し，そのうちの84名がWONに移行したが，84名のWON症例中，保存的治療を受けた23名（約27%）において局所病変の自然消失もしくは軽快が得られたと報告した。また酒井ら 12は10cmを超える巨大WONの保存的治療例を報告している。このようにWONに関する保存的治療経過の詳細は未だ不明な点もあるが，現在のガイドライン 2, 3, 4においては，膵局所合併症の種数やサイズは問わず，無症候性，非感染性の症例に対しては保存的に経過観察することが推奨され，症候性の症例では感染合併が疑われるか否か，全身状態が安定か否かにより抗菌薬投与やインターベンション治療が選択される。インターベンション治療に際しては，経皮的或いは内視鏡的経消化管的ドレナージなどの非侵襲的処置から開始し，治療効果が不十分な場合には外科的手術を行うというstep–up approach法の有用性が確認されている。 本症例はこれまでに急性膵炎を繰り返していたが，今回9か月前に発症した壊死性膵炎の際に膵尾部に造影不良域を認めたほか，結腸間膜および胃脾間に不整形脂肪織濃度上昇を認めていた。膵尾部不染領域は8か月前には最大径40mmの境界明瞭な多房性病変となり，7か月前には膵尾部病変は同サイズ，胃脾間に径50mmの嚢胞性病変，結腸間膜に径67mmの不整形脂肪織濃度上昇域を認めていた。いずれも壊死性膵炎を契機に発生しており，WONと診断し1か月ごとのCT検査を行い経過観察していた。経過中の6か月前と4か月前にはそれぞれ間質性浮腫性膵炎を発症し保存的治療を行っているが，その際はいずれの局所合併症も大きさに著変はなく，その後は2か月前のCT検査において膵尾部病変は径38mm，胃脾間病変は径41mm，結腸間膜病変は径23mmとそれぞれ縮小傾向であり，脾動脈，脾臓，胃壁の造影効果にも異常は認めなかった。したがって本症例において，脾梗塞と胃壁虚血を同時に発症したのは，膵局所合併症出現から約9か月が経過したところであった。局所合併症のサイズは続発症が増加するとされる60mmより小さい40mm前後であり，この間腹部自覚症状も認めなかったため，外来経過観察中であった。 膵局所合併症の経過中にみられる病態として，感染，消化管・胆管閉塞，腹腔内・隣接消化管や臓器への破裂・穿通，出血がある 13。本症例では胃壁虚血と脾動脈閉塞に伴う脾梗塞を発症した。膵局所合併症の消化管瘻・穿破は嚢胞性病変が消化管に癒着して線維化が進行することにより，癒着臓器の伸展が強制されて生ずると考えられる。本症例では病理所見として胃壁漿膜側にWONによる炎症波及を認め，周囲動脈内の血栓形成が散見された。炎症所見は一部固有筋層に及び，比較的広範囲の胃粘膜虚血が起き，潰瘍形成を生じたと考えられた。脾梗塞に関しては，WONによる脾動脈の物理的圧排のほか，経過中に繰り返された膵炎の炎症波及による脾動脈周囲の線維化から脾動脈狭窄を生ずる機序，血管炎に伴う血栓形成機序などの関与が考えられる。本症例は短胃動脈や胃大網動脈からの十分な側副血行路が発達する前に脾全体の梗塞を来しており，動脈周囲に好中球浸潤を伴う急性炎症所見を認めることから，徐々に進行する物理的圧迫よりも，炎症に伴って急速に進行する血栓形成の要素が大きいと考えられた。脾動脈閉塞の結果として生じた脾梗塞は，発熱，疼痛などの自覚症状が改善しない場合や，膿瘍形成，破裂，敗血症性ショック，出血などの合併症を来した場合には脾摘術の適応がある 14。梗塞範囲が増えるほど合併症のリスクが高まると考えられるが，脾機能亢進症に対して行われる部分的脾塞栓術のように，無菌性脾梗塞と適切な梗塞率が保たれていれば外科的治療を必要としないという報告 15や，胃癌術後に発症した全脾梗塞の保存的治療例の報告 16がある。本症例は当初，胃壁造影不良域を浮腫性変化と捉えていた。脾梗塞に対しては出血・感染合併による病態悪化時の手術適応を念頭に置きつつ，ヘパリン・抗菌薬・鎮痛薬による内科的治療から開始したが，発熱が続き炎症反応の改善も得られなかった。入院第4病日の再評価において脾動脈閉塞および脾梗塞の状況に変化はなく，一方で胃壁の虚血所見が明確となったため，保存的治療を断念して手術治療を行った。本症例は来院時点で左側を中心とした腹部全体の圧痛・筋性防御や非特異的炎症反応上昇という腹膜炎を疑う所見を認めており，当初からstep–up approach法に則った治療介入を検討すべきであった。本症例の術中所見においてWONは胃壁と強固に癒着していたためWONを含め一塊切除とする膵尾部切除・脾摘出・胃部分切除術を施行した。 WONの合併症治療においては，常に外科的治療に移行する選択肢を念頭に置き，症状や画像所見から臨床経過を継続的に評価することが致死的合併症を防ぐために重要である。 本症例は，繰り返す急性膵炎に生じたWONの経過観察中に脾動脈本幹閉塞からの脾梗塞および胃壁虚血を合併した。自然消退しない膵局所合併症の治療方針を検討するうえで教訓的な1例と思われ報告した。 本論文の要旨は，第49回日本救急医学会総会・学術集会において発表した。 著者全員において本症例報告に関する利益相反はない。

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

The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC. In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours. Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates. While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

FACTORS INCREASING INTRA-ABDOMINAL PRESSURE IN PATIENTS WITH A COMPLICATED COURSE OF ACUTE PANCREATITIS

Relevance. The frequency of development of intra-abdominal hypertension in patients with a complicated course of acute pancreatitis is 60-70% and leads to an increase in the mortality rate up to 62%. Acute peripancreatic fluid collection, occurring in 65.2-88.9% of patients with moderate and severe acute pancreatitis in the early period of the disease, is one of the causes of increased intra-abdominal pressure.&#x0D; Objective: to assess the effect of acute peripancreatic fluid collection on intra-abdominal pressure and the effectiveness of paracentesis with drainage of the abdominal cavity as a method of treatment of intra-abdominal hypertension in patients with complicated course of acute pancreatitis in the early period of the disease.&#x0D; Methods. The study included 60 patients with a complicated course of acute pancreatitis, who were divided into two groups depending on the features of the selected treatment tactics: the main group (paracentesis, drainage of the abdominal cavity was additionally performed) – 30 patients, the comparison group (conservative therapy was applied) - 30 patients. Intra-abdominal pressure indicators were compared in the studied groups and performed a comparative analysis of the dependence of its changes on the amount of exudate removed from the abdominal cavity.&#x0D; Results. When using paracentesis and drainage of the abdominal cavity in the early period in patients with a complicated course of acute pancreatitis, a significant difference was obtained between the intra-abdominal pressure indicators in the studied groups after one day (8.7±1.5 vs. 14.7±3.3 mm Hg (p&lt;0.0001)) and after 7 days (10.5±1.3 vs. 12.7±2.5 mm Hg (p=0.0001)). In the patients of the main group, a decrease in intra-abdominal pressure was observed on the first day after paracentesis, followed by an increase after three days and stabilization after 6 days, and an average negative correlation was found between the amount of exudate removed from the abdominal cavity and changes in intra-abdominal pressure with the Pearson coefficient r = - 0.4418.&#x0D; Conclusions. The use of paracentesis, drainage of the abdominal cavity in patients with complicated course of acute pancreatitis in the early period of the disease can be considered as a safe and effective method of treatment of intra-abdominal hypertension in this category of patients.

Incidence of peripancreatic fluid collections in patients presenting with acute pancreatitis

To calculate the incidence of acute peripancreatic fluid collection (APFC) in patients with acute pancreatitis. The secondary objective is to determine the underlying etiologies of acute pancreatitis in the Saudi population. A retrospective cohort study was carried out at King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. The study analyzed data from patients who were diagnosed with acute pancreatitis between January 2008 and January 202. A total of 327 were included in the study after applying the inclusion and exclusion criteria. Their medical records were subsequently reviewed for the presence or absence of APFC on follow-up imaging studies, evidence of biliary stones, prior endoscopic retrograde cholangiopancreatography (ERCP), a history of alcohol use, and demographic variables. Of the 327 patients with acute pancreatitis, 158 (48.3%) developed APFC, while 169 (51.7%) did not. The majority of patients had an idiopathic etiology of acute pancreatitis (n=251; 76.8%); followed by a biliary etiology (n=51; 15.6%); post-ERCP complications (n=14; 4.3%), and other causes (n=11; 3.3%). The incidence of APFC in patients presenting with acute pancreatitis between January 2008 and January 2021 was 48.3%. The most common etiology of acute pancreatitis in this tertiary care hospital was idiopathic, followed by biliary etiologies and post-ERCP complications. More studies targeting the local complications of pancreatitis are needed to reach more definitive findings.

S1894 A Case of Severe Acute Alcoholic Pancreatitis Complicated With Abdominal Compartment Syndrome

Introduction: Abdominal compartment syndrome (ACS) is a sustained intra-abdominal pressure (IAP) above 20mmHg with associated new-onset organ dysfunction. Even though it is rarely seen in clinical practice, up to 15% of patients with severe acute pancreatitis (SAP) develop ACS and have a mortality rate of up to 49%. Given that delayed treatment of ACS is associated with high mortality and adverse outcome, a higher clinical suspicion is needed to aid diagnosis. We present a case of severe pancreatitis complicated with ACS. Case Description/Methods: A 29-year-old man with a history of alcohol abuse presented with five days of severe abdominal pain. He was diagnosed with SAP. About 8 hours into admission to the ICU and resuscitation, he began having worsening work of breathing and persistent severe abdominal pain despite being on adequate opioid analgesic. Physical examination revealed tachycardia, diffuse peritoneal signs, guarding, and shock. Repeat labs revealed worsening leukocytosis, thrombocytopenia, hyperkalemia, hypocalcemia, lactic acidosis, and elevated creatinine kinase. There was also evidence of renal failure. An edematous pancreas with some peripancreatic fluid collection was evident on the CT abdomen (Figure). The abdominal x-ray was unremarkable. Indirect intra-abdominal pressure (IAP) by intravesical catheter pressure measurement was 35mmHg. He commenced medical management with neuromuscular paralysis and mechanical ventilatory support. A repeat IAP was 24mmHg. He then got surgical decompression by full-thickness midline laparotomy with wound vac placement which further reduced the IAP to 10mmHg. He received serial dialysis, correction of abnormal electrolytes, and serial transfusion with blood products as required. He remained critically ill on a mechanical ventilator and vasopressors, with a poor prognosis at the time of this writing. Discussion: The pathophysiology of elevated IAP in SAP is multifactorial. These include retroperitoneal inflammation, ascites, acute peripancreatic fluid collections, visceral edema, and aggressive fluid resuscitation. We believe some of the above listed had ensued in our patient for days before he presented to the hospital. Physical examination is inaccurate in diagnosing ACS. The first-line treatment is medical paralysis followed by surgical decompression if ineffective. We are writing this case to recommend early serial IAP measurements in patients with SAP.Figure 1.: CT abdomen showing edematous pancreas with some peripancreatic fluid collection.

S105 Acute Pancreatitis in a Los Angeles Safety Net Hospital System: Patient Characteristics and Predictors of Readmission

Introduction: Acute pancreatitis (AP) is the most common gastrointestinal cause for hospital admission in the United States and may disproportionately affect minority populations. We aimed to characterize patients with AP and identify predictors of readmission in hospitals belonging to the Los Angeles County Department of Health Services, a large safety net hospital system. Methods: A database of patient encounters at Olive View-UCLA, Harbor-UCLA, and LAC+USC Medical Centers was queried for patients seen in 2017 with an elevated lipase or diagnosis matching ICD-10-AM codes K85.0, K85.1, K85.2, K85.3, K85.8, or K85.9. Patients were included in the study if they met at least 2 of the following 3 criteria: 1) lipase >3x the upper limit of normal, 2) radiographic findings suggestive of AP, or 3) abdominal pain. Patients were excluded if radiographic evidence of chronic pancreatitis was present. Outcomes included overall length of stay (LOS), mortality due to AP during the index admission, and readmission for AP or AP-related complications. A multiple logistic regression model was used to identify predictors of readmission for AP. Results: Six hundred and twenty-three patients with median age 45 years, 83% Hispanic, and 51% male met inclusion criteria for the study. The most common AP etiology was gallstones, seen in 251 patients (40%), followed by alcohol, seen in 144 (23%). Radiographic evidence of acute interstitial edematous (IEP) and necrotizing pancreatitis (NP) was seen in 61% and 7% of patients, respectively. Greater than half of all patients with IEP developed an acute peripancreatic fluid collection, while 48% and 39% of patients with NP developed an acute necrotic collection or walled-off necrosis, respectively. The median LOS was 4 days (IQR 2 – 6). Five patients (1%) died during the index admission due to an AP-related complication, while 48 (8%) had a readmission for AP at a median of 91 days (IQR 15 – 178) from discharge. Increasing age (OR = 0.97, P = 0.038) was associated with decreased odds of readmission for AP when controlling for sex, BMI, and presence of any local complication on imaging. (Table) Conclusion: In our safety net patient population, gallstones and alcohol were the most common AP etiologies and increasing age at admission was associated with decreased odds of readmission for AP, mirroring findings reported in the literature. Our mortality rate was comparatively low at just 1%, however this may be because we did not limit our study cohort to patients with a primary diagnosis of AP. Table 1. - Predictors of readmission for AP modeled using multiple logistic regression Predictor Odds Ratio Std. Err. P-Value 95% Confidence Interval Male 1.578 0.634 0.256 0.718 – 3.470 Age 0.972 0.013 0.038 0.947 – 0.998 BMI 1.009 0.021 0.678 0.968 – 1.050 Presence of local complications 1.560 0.618 0.261 0.718 – 3.391

Natural Course of Early Detected Acute Peripancreatic Fluid Collection in Moderately Severe or Severe Acute Pancreatitis.

Background and Objectives: Acute peripancreatic fluid collection (APFC) is an acute local complication of acute pancreatitis (AP) according to the revised Atlanta classification. Sometimes APFC resolves completely, sometimes it changes into a pseudocyst or walled-off necrosis (WON), so called late complications. The aim of this study is to investigate the natural course of APFC detected on early computed tomography (CT) in moderately severe (MSAP) or severe AP (SAP). Materials and Methods: From October 2014 to September 2015, patients with MSAP or SAP were enrolled if there was APFC within 48 h of onset on imaging studies at six medical centers. The status of fluid collection was followed 4–8 weeks after onset. Initial laboratory findings, CT findings and clinical scoring systems were analyzed. Results: A total of 68 patients were enrolled and APFC was completely resolved in 32 (66.7%) patients in the MSAP group and 9 (34.6%) in the SAP group. Patients with a high bedside index for severity in acute pancreatitis (BISAP) score (≥3 points) were common in the SAP group. C-reactive protein (CRP) after 48 h from admission and BUN level were also high in the SAP group. In multivariate analysis, BISAP score (≥3 points), elevation of CRP after 48 h (≥150 mg/L) and nasojejunal feeding after 48 h were risk factors for the development of late complications. Conclusions: Spontaneous resolution of APFC was more common in MSAP group and APFC can be changed to pseudocyst or WON in patients with elevated BISAP score, CRP level after 48 h, and non-improved abdominal pain.

Safety and efficacy of intravenous hydromorphone patient-controlled analgesia versus intramuscular pethidine in acute pancreatitis: An open-label, randomized controlled trial.

Background: Hydromorphone patient-controlled analgesia (PCA) provides satisfactory postoperative pain therapy, but its effect has not been assessed in acute pancreatitis (AP). Aim: To assess the safety and efficacy of intravenous hydromorphone PCA for pain relief in AP. Methods: This open-label trial included AP patients admitted within 72 h of symptom onset, aged 18–70 years old, and with Visual Analog Scale (VAS) for pain intensity ≥5. They were randomized to receive intravenous hydromorphone PCA (0.05 mg/h with 0.2 mg on-demand) or intramuscular pethidine (50 mg as required) for three consecutive days. Intramuscular dezocine (5 mg on demand) was the rescue analgesia. The primary outcome was the change of VAS score recorded every 4 h for 3 days. Interim analysis was conducted by an Independent Data and Safety Monitoring Committee (IDSMC). Results: From 26 July 2019 to 15 January 2020, 77 patients were eligible for the intention-to-treat analysis in the interim analysis (39 in the hydromorphone group and 38 in the pethidine group). Baseline parameters were comparable between groups. No difference in VAS between the two groups was found. Hydromorphone PCA was associated with higher moderately severe to severe cases (82.1% vs. 55.3%, p = 0.011), acute peripancreatic fluid collections (53.9% vs. 28.9%, p = 0.027), more cumulative opioid consumption (median 46.7 vs. 5 mg, p < 0.001), higher analgesia costs (median 85.5 vs. 0.5 $, p < 0.001) and hospitalization costs (median 3,778 vs. 2,273 $, p = 0.007), and more adverse events (20.5% vs. 2.6%, p = 0.087). The per-protocol analysis did not change the results. Although a sample size of 122 patients was planned, the IDSMC halted further recruitment as disease worsening or worse clinical outcomes between the groups in the interim analysis. Conclusion: Hydromorphone PCA was not superior to pethidine in relieving pain in AP patients and might have worse clinical outcomes. Therefore, its use is not recommended. Clinical Trial Registration: Chictr.org.cn. ChiCTR1900025971

Gastrointestinal: Repeated acute pancreatitis and peripancreatic fluid collection caused by pancreatic intraepithelial lesion.

Gastrointestinal: Repeated acute pancreatitis and peripancreatic fluid collection caused by pancreatic intraepithelial lesion.

Comparative Analysis of Early Clinical Features and Complications of Different Types of Acute Pancreatitis.

Background Acute pancreatitis (AP) is a common surgical acute abdomen. Different kinds of pancreatitis may have different pathophysiological characteristics each other. The objective of this research was to investigate the early clinical features and complications of different types of acute pancreatitis. Methods 787 AP patients admitted in the Huadu District People's Hospital of Guangzhou during January 2009 and December 2019 were analyzed retrospectively. Among 787 AP patients, 520 (66.1%) were biliary AP (group I), 69 (8.7%) were alcoholic AP (group II), and 198 (25.2%) were hypertriglyceridemic AP (group III). According to the local and systemic complications and mortality in the early stage, we compared and analyzed the clinical characteristics and prognosis of different types of pancreatitis. Results Mild acute pancreatitis accounted for the highest proportion (79.4%) in group I, while moderately severe acute pancreatitis in group II (36.2%) and severe acute pancreatitis in group III (62.6%). In terms of severity score of the pancreatitis, the average scores of BISAP, Ranson, APACHE-II, and MCTSI of the patients in group III were the highest (p < 0.01). The incidence of acute peripancreatic fluid collection and infectious pancreatic necrosis was the highest in group III. The incidences of acute necrotic collection, pancreatic pseudocyst, and walled-off necrosis in group III were significantly higher than those in the other two groups (p < 0.01). The incidences of systemic inflammatory response syndrome, sepsis, multiple organ failure, intra-abdominal hypertension, and mortality were highest in group III. Conclusions There is an upward trend of the incidence rate of hypertriglyceridemic AP in recent years; it has been gradually developed into the second type of acute pancreatitis which is second only to the acute biliary pancreatitis. It is worthy to pay more and more attentions to it due to the feature of its younger onset, high incidence of complications, and high mortality.

Results of transgastric drainage of fluid collections and postnecrotic pancreas cysts in patients with acute pancreatitis

INTRODUCTION. The issues of treating patients with acute fluid collections and postnecrotic cysts are still relevant at the present time. Optimization of the tactics of treatment of patients at the early stages of the formation of postnecrotic cysts makes it possible to reduce the percentage of complications.The OBJECTIVE was to develop diagnostic criteria for the formation of a cyst capsule at the early stages of acute pancreatitis, to determine the optimal timing and options for transgastric drainage of cysts.METHODS AND MATERIALS. The results of treatment of 62 patients were analyzed. All patients underwent computed tomography with bolus contrast and endoscopic ultrasonography. There were 2 groups of patients who underwent surgical treatment in the early and late periods. The results of endoscopic transgastric drainage of postnecrotic pancreatic cysts were analyzed.RESULTS. Based on the analysis of the results of treatment of patients with postnecrotic pancreatic cysts and acute peripancreatic fluid collections, the data of multispiral computed tomography and endoscopic ultrasonography at the stages of cyst formation, options and optimal timing of endoscopic transgastric drainage were determined. Causes of complications accompanying this method were identified and analyzed. The technique of transgastric drainage has been improved, methods for the prevention of complications have been proposed.CONCLUSION. The obtained results make it possible to recommend diagnostic criteria and a treatment algorithm for use in clinical practice.

Effect of Early Continuous Veno-Venous Haemofiltration in Severe Acute Pancreatitis for the Prevention of Local Pancreatic Complications.

Objective To compare the conventional treatment and continuous veno-venous haemofiltration (CVVH) in severe acute pancreatitis (SAP) for the prevention of pseudocyst and walled-off necrosis. Patients and Methods. Forty-two patients were divided into two treatment groups: conventional treatment group contained 24 patients and CVVH had 18. Conventional treatment group patients were treated symptomatically and according to the causes. CVVH group patients were treated symptomatically, and CVVH was done within 2 hours of admission. Results In both groups, there was a decrease in amylase, lipase, CRP, IL-6, IL-10, TNF-alpha, Ranson score, Balthazar score, and APACHE-II score after 72 hours, but the decrease was significantly greater in CVVH patients. There were no any local pancreatic complications in CVVH patients, but 1 patient had an acute peripancreatic fluid collection, 2 patients had pseudocyst, and 2 patients had walled-off necrosis (WON), and a mortality one was seen in the conventional treatment group. Conclusion The present study shows that early CVVH may be able to prevent the formation of pseudocyst and win in SAP patients.

Not All Fluid Collections Are Created Equal: Clinical Course and Outcomes of Pancreatic Pseudocysts and Acute Peripancreatic Fluid Collections Requiring Intervention.

Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Retrospective review of patients with APFC and PP undergoing drainage (2011-2018) was performed. Patients were divided into groups based on initial intervention: surgical (SR), percutaneous (PC), or endoscopic (EN) drainage. Primary outcome was mortality by initial intervention type. Secondary outcomes included subsequent interventions required, length of stay (LOS), readmission rates, and discharge disposition. Of 88 patients, 40 (46.1%) underwent SR, 40 (44.9%) PC, and 8 (9.0%) EN. No patients in EN group had APACHE II scores>20. Pancreatic necrosis was higher in SR (80.5%) and PC (62.5%) groups (P = .006). There were no differences in mortality, LOS, or readmission rates. Ten patients in the PC group underwent subsequent surgical intervention, of which 9 were due to bowel ischemia. The PC group was 3.4 times more likely to be discharged to rehabilitation over home when compared to the other 2 groups (P = .04). Patients undergoing surgical or percutaneous drainage of APFC and PP have a greater burden of illness and more local complications requiring intervention compared to endoscopic drainage. The heterogeneity in presentation of peripancreatic fluid collections in acute pancreatitis must be considered when evaluating the benefits of each intervention.

Revised Clinical Practice Guideline of Korean Pancreatobiliary Association for Acute Pancreatitis: Treatment of Local Complication and Necrotizing Pancreatitis

In severe acute pancreatitis, accompanied by local complications such as acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis, the mortality rate is as high as 12-25%. In many cases, interventional procedure or surgical treatment are required at an appropriate time. Conservative treatment is considered for acute peripancreatic fluid collection. Endoscopic drainage could be considered preferentially for the treatment of pancreatic pseudocysts with clinical symptoms or complications. In the case of necrotizing pancreatitis, conservative treatment is preferred, but therapeutic intervention should be considered if infectious pancreatic necrosis with clinical deterioration is suspected. For therapeutic intervention, it is recommended to proceed with a step-up approach in which drainage is first performed and, if necessary, necrosectomy is performed. The optimal timing of intervention is considered 4 weeks after the onset of pancreatitis when necrosis become walled-off, but early drainage within 4 weeks can be considered depending on the patient's condition. This guideline provides an overview of current treatment strategies for local complications of acute pancreatitis.

Evaluation of Effect of Fatty Liver on the Severity of Acute Pancreatitis Using Computed Tomography- A Retrospective Study

Introduction: Fatty Liver (FL) disease is commonly encountered in clinical practice and is frequently seen in patients with Acute Pancreatitis (AP) due to common risk factors such as obesity, alcohol abuse, and insulin resistance among others. Aim: To evaluate the effect of FL on the severity of AP radiologically using Computed Tomography (CT). Materials and Methods: This was a retrospective study, conducted from June 2021 to July 2021 in which plain CT images of patients with AP were reviewed to measure the mean attenuation values of the liver and spleen. A ratio of mean hepatic/splenic Hounsfield Units (HU) &lt;1 was considered as FL. The severity of AP was assessed using the Modified CT Severity Index (CTSI) on Contrast Enhanced Computed Tomography (CECT) scan. Data collected was entered into Microsoft Excel datasheet and frequency (n) and percentages were calculated. Chi-square test was used to calculate the level of significance. Results: A total of 50 patients (44 males and 6 females; mean age 35.58±13.792 years) with AP were included in this study amongst whom FL was found in 23 patients (46%) and non FL in 27 patients (54%). The severity of pancreatitis was significantly greater in patients with FL than patients without FL. AP patients with FL had higher rates of local complications like acute Peripancreatic Fluid Collections (PPFC) (56.5% vs 22.2% p&lt;0.001) and Acute Necrotic Collections (ANC) (26.1% vs 3.7% p&lt;0.001) than those without FL. Conclusion: Fatty liver plays a significant role in the severity acute pancreatitis and can be used as an indicator for the same. Combined plain and contrast CT scans can be used to assess FL and diagnose and predict the severity of AP

S2506 Use of the Pediatric Gastroscope for Endoscopic Decompression of a Right Hydronephrosis Caused by a Peripancreatic Fluid Collection in a Patient With Severe Acute Pancreatitis

Introduction: Peri-pancreatic fluid collections can cause symptoms by compressing adjacent organs. These collections are classified as early (acute peripancreatic fluid collection or acute necrotic collection) or late (walled-off necrosis or pseudocyst). The treatment of such complication requires drainage of the collection with placement of stents between the cavity and the lumen. Case Description/Methods: A middle-aged man developed gallstone pancreatitis complicated by a large peri-pancreatic fluid collection (pancreatic pseudocyst). Four months later, he developed a right hydronephrosis caused by compression of the right ureter by the fluid collection surrounding it. He therefore underwent EUS guided cyst-gastrostomy with placement of a 20x10mm AXIOS stent and two plastic stents in the direction of the ureteral compression. In a second procedure two weeks later the XP190N pediatric gastroscope was passed through the AXIOS stent into the cavity and into the tract leading to the ureteral compression. This allowed for placement of a wire under fluoroscopic and endoscopic guidance with deployment of two plastic biliary stents. Total decompression of the ureter and resolution of the hydronephrosis ensued. Discussion: The majority of pancreatic fluid collections resolve spontaneously and do not require intervention. However, infection, pain, or compression of adjacent organs may require intervention. Treatment may include endoscopic or percutaneous catheter drainage, and later endoscopic or surgical necrosectomy. Endoscopic drainage is now the preferred approach. This case highlights the use of the XP190N pediatric gastroscope to guide deployment of a wire through a narrow fistulous tract inside the peripancreatic cavity; this allows for deployment of stents to decompress the obstruction of the right ureter. Usage of the pediatric gastroscope in this case afforded multiple advantages including enhanced navigation capabilities due to its smaller size and excellent optics; dye was directly flushed trough the channel of the scope, thus affording fluoroscopic guidance. Also, a small snare was used for necrosectomy and removal of debris. Finally, the wire was placed into the desired position for precise stents deployment. The armamentarium of dedicated endoscopic equipment for treatment of peri-pancreatic fluid collections is limited, therefore, the pediatric gastroscope should be kept in mind for use in selected cases.Figure 1.: Upper left: Peripancreatic fluid collection. Upper right: Passage of a pediatric gastroscope through the AXIOS stent with wire placement in the peri-ureteral space. Lower left: Two plastic stent deployed for decompression of the ureteral obstruction. Lower right: Total resolution of the obstruction of the right ureter.