Cases Of Severe Acute Pancreatitis Research Articles

Clinical report and multidisciplinary team discussion of two fatal cases of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in 20% of patients with acute pancreatitis (AP). Patients with SAP are at a higher risk of systemic and local complications and often need invasive interventions. In order to assess the importance of multidisciplinary collaboration mode in the diagnosis and treatment of SAP, an international multidisciplinary discussion was held for two patients, who died of SAP. Through the multidisciplinary discussion, the recent relevant literature was reviewed and the experiences and lessons from these two cases were summarized.

A Multicenter, International Cohort Analysis of 1435 Cases to Support Clinical Trial Design in Acute Pancreatitis.

BackgroundC-reactive protein level (CRP) and white blood cell count (WBC) have been variably used in clinical trials on acute pancreatitis (AP). We assessed their potential role.MethodsFirst, we investigated studies which have used CRP or WBC, to describe their current role in trials on AP. Second, we extracted the data of 1435 episodes of AP from our registry. CRP and WBC on admission, within 24 h from the onset of pain and their highest values were analyzed. Descriptive statistical tools as Kruskal–Wallis, Mann–Whitney U, Levene’s F tests, Receiver Operating Characteristic (ROC) curve analysis and AUC (Area Under the Curve) with 95% confidence interval (CI) were performed.ResultsOur literature review showed extreme variability of CRP used as an inclusion criterion or as a primary outcome or both in past and current trials on AP. In our cohort, CRP levels on admission poorly predicted mortality and severe cases of AP; AUC: 0.669 (CI:0.569–0.770); AUC:0.681 (CI: 0.601–0.761), respectively. CRP levels measured within 24 h from the onset of pain failed to predict mortality or severity; AUC: 0.741 (CI:0.627–0.854); AUC:0.690 (CI:0.586–0.793), respectively. The highest CRP during hospitalization had equally poor predictive accuracy for mortality and severity AUC:0.656 (CI:0.544–0.768); AUC:0.705 (CI:0.640–0.769) respectively. CRP within 24 h from the onset of pain used as an inclusion criterion markedly increased the combined event rate of mortality and severe AP (13% for CRP > 25 mg/l and 28% for CRP > 200 mg/l).ConclusionCRP within 24 h from the onset of pain as an inclusion criterion elevates event rates and reduces the number of patients required in trials on AP.

A step-up drainage combined with thermostatic lavage in the management of infected pancreatic necrosis

Objective To investigate the safety and efficacy of a step-up drainage combined with thermostatic lavage in the management of severe acute pancreatitis complicated with infected pancreatic necrosis. Methods From January 2014 to July 2017, 100 cases of severe acute pancreatitis complicated with infected pancreatic necrosis admitted to our hospital were prospectively collected. All patients were randomly (random number) assigned into the observation group and control group with 50 cases in each group. The patients in both groups were given a step-up drainage. Moreover, patients in the observation group received lavage under constant temperature (30-35 °C) while the patients in the control group were at room temperature. The clinical prognosis of the two groups was observed. Results When compared with the control group, patients in the observation group got a lower rate of new onset renal injury (16.00% vs 34.00%, P=0.038); a lower rate of new onset gastrointestinal dysfunction (12.00% vs 28.00%, P=0.046); a reduced mechanical ventilation time[ (14.82±7.78)vs (18.64±8.12)d, P=0.018]; a decreased continuous blood filtration [(12.98±6.20) vs (18.56±10.92)d, P=0.002]; and a shorter hospital duration [(43.28±10.72) vs (50.82±12.74) d, P=0.002]. No significant difference was found in the APACHEⅡscore between the two groups at admission and at the time of puncture [(9.88±2.40) vs (9.46±2.35), P=0.378 and (10.30±3.07 vs (10.54±2.96), P=0.692]. At 7 and 14 days after the puncture, the APACHE II score in the observation group was significantly lower than that in the control group [(9.32±2.49) vs (10.56±2.80), P=0.021 and (6.20±2.54 vs (8.42±2.48), P<0.01]. Conclusions A step-up drainage combined with constant temperature lavage can reduce the incidence of new renal failure and gastrointestinal dysfunction in infected pancreatic necrosis patients and improve the clinical prognosis of the patients. Key words: Thermostatic lavage; Severe acute pancreatitis; Organ failure

Retrospective Matched-Cohort Analysis of Acute Pancreatitis Induced by 5-Aminosalicylic Acid-Derived Drugs.

This study aimed to compare the clinical course of 5-aminosalicylic acid-derived, drug-induced acute pancreatitis (5-ASA-DIAP) to acute pancreatitis (AP) caused by other etiologies. A cohort of patients with 5-ASA-DIAP was established through literature search. As a control AP (CAP) group, a cohort was generated from a registry. Data on the diagnostic procedure, symptoms, enzyme elevation, imaging, severity, and recovery parameters were collected. Causality was assessed using the Naranjo algorithm. Twenty-nine articles were included, which describe 36 patients with fifty-one 5-ASA-DIAP episodes (60.78% female, 39.22% male). There were 88.2% mild, 3.92% moderate, and 7.84% severe cases of AP in the 5-ASA-DIAP group, and 70.6%, 25.5%, and 3.92% such cases in the CAP population, respectively. Symptoms improved significantly faster (mean ± SE, 2.5 ± 0.34 vs 3.74 ± 0.42 days; P = 0.018); however, pancreatic enzyme levels normalized significantly more slowly (6.27 ± 1.53 vs 3.63 ± 0.61 days, P = 0.008) in the 5-ASA-DIAP cohort compared with the CAP group. This study confirms that there are no diagnostic differences between 5-ASA-DIAP and AP of other etiologies. Fewer moderate but more severe cases were found in the 5-ASA-DIAP group; therefore, 5-ASA-DIAP must be taken as seriously as AP of other etiologies.

A Rare Case of Severe Acute Pancreatitis in an Adult Caused by Type 1 Choledochal Cyst (CC)

A Rare Case of Severe Acute Pancreatitis in an Adult Caused by Type 1 Choledochal Cyst (CC)

Two Cases of Severe Acute Pancreatitis Following Duodenal Papillary Biopsy

Two Cases of Severe Acute Pancreatitis Following Duodenal Papillary Biopsy

A Case of Severe Acute Pancreatitis With Multiple Colon and Stomach Perforations Required Surgical Approach for Remission

A Case of Severe Acute Pancreatitis With Multiple Colon and Stomach Perforations Required Surgical Approach for Remission

The Role of Serum High Mobility Group Box 1 and Interleukin-6 Levels in Acute Pancreatitis: A Meta-Analysis.

The purpose of this meta-analysis was to comprehensively investigate the correlation between high mobility group box 1 (HMGB1) and interleukin-6 (IL-6) in relation to acute pancreatitis. A highly regulated exploration of various electronic databases, supplemented by manual searching methods, was performed in an attempt to identify pertinent articles of a useful nature. Subsequently, high-quality cohort studies that were deemed to comply with the arduous inclusion and exclusion criteria were selected for our meta-analysis. The extensive data analyses reported in our meta-analysis were conducted in connection with the Comprehensive Meta-analysis 2.0 (CMA 2.0). A total of 395 studies (135 Chinese studies and 260 English studies) were initially retrieved. 27 of those studies were selected for our meta-analysis, comprising of 896 cases of mild acute pancreatitis (MAP), 700 cases of severe acute pancreatitis (SAP) as well as 312 healthy controls. Pooled data suggested that serum HMGB1 and IL-6 levels of SAP and MAP patients were higher than in healthy controls. Moreover, serum HMGB1 and IL-6 levels of SAP patients exhibited significantly higher levels than in that of MAP patients. Based on the rigorous investigation of our meta-analysis, it was concluded that serum HMGB1 and IL-6 levels might be used as effective indicators for pancreatic lesions as well as the degree of inflammatory response, owing ultimately to the observations and data analyses, suggesting that serum HMGB1 and IL-6 levels share a close correlation with the severity of pancreatitis. J. Cell. Biochem. 119: 616-624, 2018. © 2017 Wiley Periodicals, Inc.

A prospective study to predict the severity of acute pancreatitis by BISAP score

Background: Acute pancreatitis (AP) is as an inflammation of the pancreas with varied range of complication like peri-pancreatic collection, pancreatic necrosis, renal failure, multi-organ dysfunction syndrome which increases mortality rate and morbidity. Majority of AP cases are mild but severe cases of AP are associated with increased complication and mortality. BISAP is simple bedside prognostic scoring system for predicting severity of AP. BISAP is a collection of simple routine investigation and scores are quantified at 24hours of onset of AP. This study aims to assess prognosis of AP cases at ESIC Medical college and Post Graduate Institute of Medical Science and Research, Bangalore, Karnataka, India.Methods: A prospective study of 60 Patients who were diagnosed as AP according to RAC. All patients were admitted in high dependency unit with close observation of vital parameters and investigations were done at 24 hours of onset of AP. BISAP score &gt;3 was considered as Severe Acute Pancreatitis, its correlation with local complications, organ failure, ICU stay and Mortality was studied. Statistical analysis done using Chi-square test and Fisher Exact test for local complications and organ failure using xL Stat and SPSS v.21.0, a p-value &lt;0.05 was considered to be significant.Results: Of the 60 patients, BISAP score was &gt;3 and &lt;3 in 15 and 45 patients respectively. Alcohol was the most common cause of acute pancreatitis, accounting for 53.33%. In current study 12 (20%) patients developed organ failure and among them 9 (75%) had transient organ failure and 3 (25%) had persistent organ failure. Total 8 (13%) patients had developed pancreatic necrosis and among them 6 had BISAP &gt;3. Mortality rate in this study was 2%.Conclusions: The BISAP score is a simple and fairly accurate method for the early identification of patients at increased risk for in hospital mortality and to identify patients at risk of the development of intermediate markers of severity and organ failure within 24 hours of presentation.

An autopsy case of severe acute pancreatitis caused by Clostridium perfringens infection accompanied by pneumoretroperitoneum

An autopsy case of severe acute pancreatitis caused by <i>Clostridium perfringens</i> infection accompanied by pneumoretroperitoneum

Electroacupuncture for severe acute pancreatitis accompanied with paralytic ileus:a randomized controlled trial

To observe the clinical efficacy differences between electroacupuncture (EA) and regular treatment for severe acute pancreatitis accompanied with paralytic ileus. This was a prospective pragmatic randomized controlled trial. A total of 140 cases of severe acute pancreatitis accompanied with paralytic ileus were randomly assigned into an EA group and a regular treatment group, 70 cases in each one. The patients in the regular treatment group were treated with regular treatment, including intensive care, gastrointestinal decompression, fasting, blood capacity supplement, acid suppression treatment, internal environment maintenance, infection prevention, inhibition of pancreatic exocrine secretion, etc. Based on the regular treatment, patients in the EA group were treated with EA at Zusanli (ST 36) and Zhigou (TE 6), 30 min for each treatment, once a day for totally 5 days. The VAS-based abdominal distension severity scale and abdominal pain severity scale were compared before and during treatment in the two groups, moreover, the number of patients who transferred to surgery or ICU was compared. (1) After the 1st EA, the abdominal pain and distension severity scales were both improved in the EA group, which were superior to those of the regular treatment group (all P<0.05); afterwards, the abdominal distension and pain severity scales of each day in the EA group were all significantly superior to those of the regular treatment group (all P<0.05). (2) The number of patients who transferred to surgery or ICU was not significantly different between the two groups (P>0.05). EA at Zusanli (ST 36) and Zhigou (TE 6) can significantly reduce the abdominal distension and pain severity scales in patients of severe acute pancreatitis accompanied with paralytic ileus, indicating positive clinical significance; in addition, EA is safe and can be recommended to the treatment of severe acute pancreatitis in combination with treatment plan of integrated Chinese and western medicine.

Analysis of strategic debridement of 62 cases of severe acute pancreatitis without biliary obstruction

Analysis of strategic debridement of 62 cases of severe acute pancreatitis without biliary obstruction

Resistin: New serum marker for predicting severity of acute pancreatitis.

ObjectiveTo assess the effectiveness of resistin in predicting the severity of acute pancreatitis.MethodsPatients with acute pancreatitis who presented at the Gastroenterology Clinic, Erzurum Education and Research Hospital, Turkey were enrolled in this prospective study. White blood cell (WBC), C-reactive protein (CRP) and resistin levels were measured on admission and at 24 h, day 3 and day 7 following admission, along with other blood parameters. Patients were divided into two groups: mild acute pancreatitis and moderate/severe acute pancreatitis.ResultsOf 59 patients with acute pancreatitis (mild, n = 37; moderate/severe, n = 22), significant between-group differences were found in terms of resistin and CRP levels. Receiver operating curve analysis showed that resistin levels were better for predicting severe cases of acute pancreatitis than CRP or WBC levels on day 3 (area under the curve [AUC], 0.88 versus 0.81 and 0.63, respectively). Resistin levels on day 3 were better than CRP levels for predicting necrosis development (AUC, 0.70 versus 0.69, respectively).ConclusionsResistin may represent a new, effective indicator to predict the severity of acute pancreatitis and presence of necrosis in patients with acute pancreatitis.

Acute pancreatitis complicated by rupture of abdominal aortic aneurysm.

Acute pancreatitis complicated by rupture of abdominal aortic aneurysm.

Analysis of bacterial spectrum and drug resistance in 50 cases of severe acute pancreatitis complicated with infection

Objective To investigate the bacterial spectrum changes and characteristics of drug resistance of patients with severe acute pancreatitis (SAP) and to guide clinical proper use of antibiotics medicine. Methods Clinical specimens of 50 patients with SAP were analyzed including sputum, blood, urine, central venous catheter, bile, et al. Bacterial strains were regularly isolated and drug sensitivity test was made by disc diffusion method. Chi-square test was performed for statistical analysis. Results One hundred and fifty-six bacterial strains were isolated. The number of strains isolated from the sputum, blood, pancreas and abdominal cavity, bile, urine tract, surgical incision, oral secretion was 51, 37, 24, 23, 11, 8 and 2, respectively. The most common bacterial strains were Acinetobacter baumannii, Escherichia coli, Pseudomonas aeruginosa and Enterococcus faecium, the number of strains was 30, 21, 20 and 14, respectively. The drug resistance rate of Acinetobacter baumannii to imipenem and meropenem was no less than 90%. The drug resistance rate to cefoperazone/sulbactam was lower, but still over 60%. The drug resistance rate of Escherichia coli to penicillins, majority of cephalosporins and quinolones was over 90%. The drug resistance rate of Pseudomonas aeruginosa to partial cephalosporins was high (90%), and the drug resistance rate to imipenem was also up to 65%. The drug resistance rate of Enterococcus faecium to penicillin G and quinolones was up to 100%. No Enterococcus resistant to tigecycline, vancomycin and linezolid was found. The infection rate of patients received invasive operation was higher than that of patients received no invasive operation. Conclusions The main bacteria of patients with SAP complicated with infection was Gram-negative bacteria, which has high drug resistance. The common locations of infection were respiratory tract, blood, abdominal cavity, biliary system and urinary tract. The infection in respiratory tract and blood may be related with invasive medical operations. Key words: Severe acute pancreatitis; Complicated with infections; Drug resistance

Acute Pancreatitis : A More Common and Severe Complication of Gallstones in Males

To describe an increased incidence and severity of gallstone pancreatitis in males compared to females. This is a retrospective observational comparative study conducted at Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, over 3 years from June 2008 to June 2011. The study includes two hundred and thirty seven (237) patients with a mean age of 52.38, Std 13.311,65 (22-87) with 157 (66.24%) females and 80 (33.75%) males who were admitted as acute abdominal pain secondary to gallstones. The patients were mostly diagnosed on ultrasonography and enzyme studies. Demographics and other variables are studied and statistical analysis done on SPSS version 20. More frequent cases of severe acute pancreatitis were observed in males with gallstones (70%) compared to females (P<0.001). The aged people had a high prevalence while males were more likely to develop local and systemic complications. Severity stratification was done based on different criteria's like Ranson's criteria, and APACHEII. Overall mortality was 7.59%. Mortality among males was significantly high (70%, n=16) in our study due to an increased incidence of fulminant course of the disease. Contrary to the belief, gallstone associated acute pancreatitis is getting more common in our society and especially so in male population.

Six cases of severe acute pancreatitis complicated with vancomycin-resistant enterococcus enteritis.

The objective of this study was to explore the clinical manifestations and possible mechanisms of vancomycin-resistant enterococcus (VRE)-induced severe enteritis and extraenteric disseminations. In six patients with severe acute pancreatitis (SAP) complicated with acute infectious diarrhea, VRE was confirmed by bacterial genotyping, minimum inhibitory concentration testing, and empiric linezolid treatment. Samples collected from stools and peripancreatic effusions were used to compare the genotypes of VRE by pulsed-field gel electrophoresis and multilocus sequence typing and to validate the suspected extraenteric disseminations caused by VRE. To further elucidate the mechanisms of VRE-inflicted enteric mucosal injury, in vitro infection of human intestinal Caco-2 cell line with VRE was performed followed by inflammatory cytokine assays and morphological characterization by electron microscopy. All six VRE strains isolated from stool samples caused severe enteritis in SAP patients. The same strains further inflicted significant damage and induced inflammatory reactions in Caco-2 cells. Homologous assays demonstrated high homology between samples from stool and peripancreatic effusions in two patients, indicating the occurrence of extraenteric disseminations. Alterations in drug resistance and virulence of enterococci, part of the symbiotic bacteria, during the course of SAP may cause inflammatory injuries to enteric epithelium, resulting in enteritis and extraenteric disseminations.

Evolution and Results of the Surgical Management of 143 Cases of Severe Acute Pancreatitis in a Referral Center

IntroductionSurgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centers in Spain have published their results of surgery for acute pancreatitis. ObjectiveTo review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. Materials and methodsWe have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyze the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed. ResultsA total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (<7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of <7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures. ConclusionsPancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

The prognostic value of CD14＋HLA-DRlow/-for evaluating the severity of acute pancreatitis

Objective To investigate the prognostic value of CD 4＋CD25＋/high CD127 low/-and CD14＋HLA-DRlow/-for evaluating the severity of acute pancreatitis .Methods The percentages of CD4＋CD25＋/highCD127low/-and CD14＋HLA-DRlow/-and the CD64 index were measured by flow cytometry in pa-tients with acute pancreatitis （ including 43 cases of mild acute pancreatitis and 24 cases of severe acute pan-creatitis）.Moreover, the levels of C-reactive protein （CRP）, acute physiology and chronic health evaluationⅡ（ APACHEⅡ） score and CT severity index （ CTSI ） were detected for a correlation analysis .Results The percentages of CD4＋CD25＋/highCD127low/-and CD14＋HLA-DRlow/-and the CD64 index in patients with severe and mild acute pancreatitis were significantly higher than those in healthy subjects .Patients with se-vere acute pancreatitis showed higher percentages of CD 14＋HLA-DRlow/-than patients with mild acute pan-creatitis.With the disease progression, the CD64 index and the levels of CD4＋CD25＋/highCD127low/-, CD14＋HLA-DRlow/-and CRP were significantly dropped after an initial increase in patients with mild acute pancrea -titis, while these indexes were continuously elevated in patients with severe acute pancreatitis .The percent-age of CD14＋HLA-DRlow/-was positively correlated with CD64 index, CRP level, APACHEⅡ score and CTSI.Conclusion CD14＋HLA-DRlow/-level was closely related to the severity of acute pancreatitis , which could be used as immune parameter for the estimation of the clinical severity of acute pancreatitis . Key words: Acute pancreatitis; CT severity index; CD64 index; Flow cytometry

Authors' Response

To the Editor: We thank Dr Fabre and colleagues for their interest in our study regarding the use of serum lipase concentrations as an early predictor of severity in pediatric acute pancreatitis (AP) (1), and for sharing the results of their analysis in their own patient population. We assume that all levels were performed within 24 hours of presentation. In particular, their finding of serum lipase ≥7 × upper limit of normal (ULN) predicting severe AP in children is strikingly similar to our own results in a separate patient population, further validating this finding. As indicated, when compared with previously validated severity scores in AP, the sensitivity of serum lipase ≥7 × ULN within 24 hours of presentation (85% in Coffey et al (1) and 80% in Fabre et al) was superior to the Ranson, Glasgow, and DeBanto Scale scores (with sensitivities of 62%, 54%, and 54%, respectively) but with poorer specificity (2). We agree that to date, an early predictor of severe AP in children with both high sensitivity and specificity has not yet been identified. For now, we propose that serum lipase may be used for risk stratification (to rule out most cases of severe AP) within 24 hours of presentation, whereas scoring systems such as the DeBanto (3), Ranson (4), and Glasgow (5) could be applied after 48 hours to provide adjunctive prognostic information.