Development Of Infected Pancreatic Necrosis Research Articles

Predictive Risk Factors of Pancreatic Exocrine Insufficiency Developed After Acute Pancreatitis: A Retrospective Cohort Study.

The aim of this study was to compare the clinical characteristics of acute pancreatitis (AP) patients between those who developed pancreatic exocrine insufficiency (PEI) and those who did not, and to investigate the predictive factors of PEI. From October 1st 2019 to July 30th 2021, AP patients admitted at our center were included. The fecal elastase-1 assay was adopted for PEI diagnosis. The clinical characteristics, treatments, and outcomes between the patients with and without PEI were analyzed. In total, 63 males and 42 females were included. There were 27 patients with mild AP, 54 with moderately severe AP, and 24 with severe AP. The median modified computed tomography severity index (MCTSI) was 6.000(4.000, 8.000). During the follow-up, 38 patients developed PEI after AP. The univariate analysis showed that higher ASA grade (P = 0.006), more severe AP (P = 0.000), the presence of multiple organ dysfunction syndrome (P = 0.030), higher MCTSI (P = 0.000), the development of infected pancreatic necrosis (P = 0.002) and local complications (P = 0.000), higher levels of triacylglycerol (P = 0.022), video-assisted retroperitoneal debridement intervention (P = 0.015), and longer intensive care unit stay (P = 0.044) were correlated with PEI development. Furthermore, the logistic regression analyses showed that MCTSI during hospitalization is an independent risk factor for PEI development during the AP recovery period. ASA grade, severity of AP, multiple organ dysfunction syndrome, MCTSI, infected pancreatic necrosis, local complications, higher levels of triacylglycerol, video-assisted retroperitoneal debridement intervention, and longer intensive care unit stay were potentially associated with PEI development during the AP recovery period. High MCTSI was independently associated with the development of PEI during the AP recovery period, which may help alert to the possibility of PEI to help with its early detection and treatment.

The Role of Phosphatidylethanolamine-N-methyltransferase (PEMT) Gene rs12449964 Polymorphism in the Development of Acute Pancreatitis and its Complications

Background. Acute pancreatitis is considered to be an important issue in modern medicine. The phosphatidylethanolamine-N-methyltransferase enzyme plays a significant role in the regulation of lipid metabolism by catalyzing the process of methylation of phosphatidylethanolamine to phosphatidylcholine. These lipids are key components of mitochondrial and cell membranes, providing their fluid and plastic properties and participating in the transport of fats, fatty acids and cholesterol. Along with its function in the synthesis of phosphatidylcholine, the methylation of phosphatidylethanolamine promotes the turnover of S-adenosylmethionine for the synthesis of cysteine and glutathione through transulphurisation. PEMT is a gene encoding the phosphatidylethanolamine-N-methyltransferase enzyme.Aim. To determine the role of PEMT C/T rs12449964 polymorphism in the risk of developing acute pancreatitis and its complications among Russian residents in Central Russia.Materials and methods. Whole blood samples were collected from 502 unrelated patients with acute non-biliary pancreatitis (97 women and 405 men) of Russian nationality who had been admitted to the surgical departments of the city of Kursk from 2015 to 2018, as well as from 513 unrelated individuals of Russian nationality without gastrointestinal diseases (101 women and 412 men). The average age of patients and healthy individuals was 48.9 ± 13.1 and 47.89 ± 12.1 years, respectively. Genomic DNA was isolated by a standard phenol-chloroform extraction method. Genotyping of rs12449964 polymorphism was performed using real-time PCR by allelic discrimination using a CFX96 Bio-Rad Laboratories amplifier (USA) with TaqMan probes and commercial TaqMan SNP Genotyping Assays reagents purchased from Applied Biosystems (USA).Results. The study has shown that the frequency of the C allele and the C/C PEMT C/T rs12449964 genotype was higher in the group of patients with acute pancreatitis, while the C/T genotype was predominant in the control group. C/T — T/T genotypes demonstrated a protective effect on the development of infected pancreatic necrosis, purulent necrotic peripancreatitis and severe acute pancreatitis.Conclusions. The disruption of phosphatidylethanolamine methylation processes increases the sensitivity of cells to oxidative stress, which can lead to the development of acute pancreatitis.

Mechanism of Increased Intestinal Permeability in Acute Pancreatitis: Alteration in Tight Junction Proteins.

Intestinal permeability (IP) has been shown to be increased in acute pancreatitis (AP) and is considered to be responsible for development of septic complications. However, the mechanism of increase in IP is not well studied. We studied whether alteration in tight junction proteins (TJP) has any role in altered IP in patients with AP. This is a prospective study conducted at a tertiary care referral center. Twenty consecutive moderate and severe AP patients fulfilling the study criteria were included along with 20 controls that underwent gastroduodenoscopy for dyspepsia. IP was measured with lactulose mannitol (LM) ratio and TJP were studied by measuring expression of claudin-2 and claudin-4 in duodenal biopsy samples. Statistical analysis was done with STATA 13.0. IP as depicted by LM ratio was significantly higher in AP patients as compared with controls (4.659±10.4 vs. 0.101±0.297; P<0.001). Claudin-4 expression was reduced in duodenal biopsies in AP patients (P<0.001 for crypt intercellular junction and P=0.007 for crypt cytoplasm). However, LM ratio was not associated with either mortality (P=0.12) or development of infected pancreatic necrosis (P=0.3). IP is increased in AP. Alteration in TJP in the form of reduced claudin-4 expressions could be the possible mechanism for increased IP.

Hypotension in the First Week of Acute Pancreatitis and APACHE II Score Predict Development of Infected Pancreatic Necrosis

Hypotension and intestinal mucosal ischemia lead to bacterial translocation from the gut lumen into systemic circulation. The purpose of this study was to determine the strength of association between different types of organ failure (OF): hypotension (cardiovascular system failure), renal failure, respiratory failure, CNS failure and coagulopathy in the first week of acute pancreatitis (AP) and the subsequent development of infected pancreatic necrosis (IN). Consecutive patients with AP were evaluated for OF and its severity in the first week of hospital admission. Modified multiple organ failure score (MOFS) was used to identify and grade severity of OF. MOFS of ≥2, lasting for more than 48 h was defined as OF. Occurrence of IN (isolation of bacteria in necrosectomy specimen or image guided fine needle aspiration of pancreatic necrosis) was compared between groups with and without OF. Of the 81 patients, mean age was 40.1 ± 14.4 years and 55 were males; 60 (74 %) patients had OF and 13 (16 %) patients had IN. Occurrence of IN was not significantly different between patients with OF (18.3 %) and without OF (14.3 %), p = 0.48. However IN occurred in 10 % of patients without and 33.7 % patients with hypotension, p = 0.01. The rest of the organ systems analyzed did not show any significant difference in occurrence of infected necrosis. On multivariate analysis independent predictors of occurrence of IN were hypotension (odds ratio, OR 2.5, p < 0.001) and APACHE II score at 24 h of hospital admission (OR 4.77, p < 0.001). Hypotension in the first week of AP and APACHE II score predict development of IN.

Could rising BUN predict the future development of infected pancreatic necrosis?

BackgroundInfected (peri)pancreatic necrosis (IPN) in acute pancreatitis (AP) is associated with organ failure (OF) and high mortality. There are no established early markers of primary IPN. This study aimed to assess the association of simple parameters with primary IPN in AP. MethodsWe retrospectively studied 281 patients with AP admitted to Mayo Clinic hospitals and identified those with microbiologically confirmed infections in (peri)pancreatic necrosis and collections. We defined primary IPN as infection of (peri)pancreatic necrotic tissue that developed before interventions. We recorded admission hematocrit, BMI, BUN, serum creatinine, SIRS score and development of persistent organ failure within 48 h of admission; and performed serial SIRS and BUN calculations for at least 48 h. We used univariate and multivariable analysis to assess associations and expressed results as odds ratio (OR)[95% CI]. Results27 (9.6%) patients developed IPN, of which 21 (77.7%) had primary IPN. 38.1% had Gram positive, 9.5% Gram negative and 52.3% mixed bacterial infections. Five (23.8%) of the patients with IPN had fungal infection. On univariate analysis, SIRS ≥ 2 at admission, rise in BUN by 5 mg/dL within 48 h of admission, persistence of SIRS for 48 h and development of persistent OF within 48 h of disease had significant association with development of primary IPN with OR (95% CI) of 4.12 (1.53–11.15), 10.25 (3.95–26.61), 1.19 (1.69–10.39) and 7.62 (2.58–21.25) [2-tailed p = 0.004, <0.0001, 0.002 and <0.0001] respectively. On multivariable analysis, only rise in BUN by 5 mg/dL within 48 h of admission was associated with primary IPN (p = 0.007). ConclusionsRising BUN within 48 h of admission can be used to predict development of primary IPN in AP.

Minimally Invasive Management of Acute Necrotizing Pancreatitis

About 10% to 20% of patients with acute pancreatitis develop severe disease, which is characterized by intrapancreatic or peripancreatic necrosis [1-6]. Necrotizing pancreatitis is the most severe form of acute pancreatitis associated with high morbidity and mortality due to the development of infected pancreatic necrosis, and multisystem organ failure. In severe necrotizing pancreatitis, the mortality rate ranges from 10% to 40%, and it is especially high (up to 50%) when the necrosis is infected and progressing to sepsis and multiorgan failure [1-3,7]. The appropriate treatment of infected pancreatic necrosis remains the subject of much debate. It is generally accepted that in infected necrotizing pancreatitis the infected non-vital solid tissue has to be removed in order to control the sepsis. For decades, open surgery and immediate surgical necrosectomy was the gold standard treatment for patients with infected pancreatic necrosis [1,3,7,8]. However, several reports have shown that early surgical intervention for pancreatic necrosis could result in a worse prognosis compared to cases where surgery is delayed or avoided [9-13]. It has been suggested that the invasiveness of open surgery in an already critically ill patient may be the cause of high morbidity rates. Therefore, several groups worldwide have developed new minimal invasive approaches using conservative treatment, endoscopic necrosectomy or drainage therapy in the management of infected necrotizing pancreatitis [14-19].

Hypotension in the First Week of Acute Pancreatitis Predisposes to Development of Infected Pancreatic Necrosis

Hypotension in the First Week of Acute Pancreatitis Predisposes to Development of Infected Pancreatic Necrosis

The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: Systematic review

Many studies have evaluated serum levels of procalcitonin (PCT) as a predictor in the development of severe acute pancreatitis (SAP) and infected pancreatic necrosis (IPN). This study assesses the value of PCT as a marker of development of SAP and IPN. Medline, Web of Science, the Cochrane clinical trials register, and international conference proceedings were searched systematically for prospective studies, which evaluated the usefulness of PCT as a marker of SAP and IPN. The sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated for each study, and the study quality and heterogeneity among the studies were evaluated. Twenty-four of 59 studies identified were included in data extraction. The sensitivity and specificity of PCT for development of SAP were 0.72 and 0.86, respectively (area under the curve [AUC] = 0.87; DOR = 14.9; 95% confidence interval [CI] = 5.6-39.8), albeit with a significant degree of heterogeneity (Q = 28.56, P < .01). The sensitivity and specificity of PCT for prediction of infected pancreatic necrosis were 0.80 and 0.91 (AUC = 0.91; DOR = 28.3; 95% CI = 13.8-58.3) with no significant heterogeneity (Q = 7.83, P = .18). No significant heterogeneity was observed among the studies when only higher quality studies (AUC = 0.91; DOR = 30.7; 95% CI = 10.7-87.8) or studies that used a cutoff PCT level >0.5 ng/mL (AUC = 0.88, 32.8; 95% CI = 10.1-106.6) were included. Serum measurements of PCT may be valuable in predicting the severity of acute pancreatitis and the risk of developing infected pancreatic necrosis.

Meta-analysis of prophylactic parenteral antibiotic use in acute necrotizing pancreatitis

Acute pancreatitis is a potentially serious condition. It carries an overall mortality rate of 10-15%. Infectious complications account for approximately 80% of deaths from acute pancreatitis, and the question arises whether or not prophylactic antibiotics are useful in the prevention of these complications. Therefore, we performed an evidence-based analysis to assess the effect of available prophylactic antimicrobial treatment on the development of infected necrosis and sepsis, need for surgery, and mortality. A comprehensive PubMed search was performed evaluating the value of prophylactic administration of parenteral antibiotics in patients with acute necrotizing pancreatitis. Only articles published in English language between January 1990 and May 2006 were included. The search strategy initially generated 692 articles related to antibiotics in the treatment of acute pancreatitis. This number was reduced to 97 publications related to clinical trials on the same topic. Finally, 10 randomized clinical trials concerning prophylactic parenteral antibiotics in patients with acute necrotizing pancreatitis were identified. We have performed a meta-analysis using the random-effects model to assess the impact of prophylactic antibiotics on development of infected pancreatic necrosis and sepsis, need for surgery, and overall mortality. Patients with necrotizing acute pancreatitis should receive effective antibiotic prophylaxis (i.e., carbapenems intravenously) to decrease the risk of infected necrosis and sepsis and need of surgery. While providing new insights into key aspects of antibiotic prophylaxis, this evidence-based analysis highlights the need for further clinical trials regarding the indications for antibiotic prophylaxis.

Value of routine clinical tests in predicting the development of infected pancreatic necrosis in severe acute pancreatitis

Objective. Fine-needle aspiration (FNA) is the procedure of choice for accurate diagnosis of infected necrosis. However, invasive procedures increase the risk of secondary pancreatic infection and the timing of FNA is still a matter for debate. Our objective was to assess the value of routine clinical tests to determine the minimal risk for infected necrosis, thereby optimizing timing and selection of patients for image-guided FNA. Material and methods. This prospective, non-randomized study comprised 90 patients with acute necrotizing pancreatitis. The data of 52 patients were used for discriminant function analysis to determine the differences between patients with infected necrosis and those with sterile necrosis. Cut-off points for variables were established using receiver operating characteristic (ROC) curve analysis and logistic regression was performed to determine the risk of infected necrosis. The clinical relevance of the defined diagnostic system was prospectively tested in a further 38 consecutive patients with acute necrotizing pancreatitis (ANP). Results. Discriminant function analysis showed that C-reactive protein (CRP) and white blood cell (WBC) values were significant discriminators between patients with sterile necrosis and those with infected necrosis. Cut-off values of 81 mg/l for CRP and 13×109/l for WBC were established. The predicted risk for infected necrosis is approx. 1.4% if both tests are below the defined cut-off values. Consequently, we found FNA unnecessary in this subset of patients, unless otherwise indicated, as this invasive procedure per se carries a certain risk of bacterial contamination. Conclusions. Routine clinical tests are helpful in diagnosing the development of infected necrosis. Based on the application of classification functions, the timing and selection of patients for image-guided FNA can be optimized.

Acute Pancreatitis: The Role of Imaging and Interventional Radiology

Acute pancreatitis can manifest as a benign condition with minimal abdominal pain and hyperamylasemia or can have a fulminant course, which can be life-threatening usually due to the development of infected pancreatic necrosis, and multisystem organ failure. Fortunately, 70-80% of patients with acute pancreatitis have a benign self-limiting course (figs. 1, 2, 4). The initial 24-48 hours after the initial diagnosis is usually the period that determines the subsequent course, and for many of the 20-30% of patients who subsequently have a fulminant course, this becomes apparent within this time frame. With reference to long-term outcome following acute pancreatitis, most cases recover without long-term sequelae with only a minority of cases progressing to chronic pancreatitis. In the initial management of acute pancreatitis, assessment of metabolic disturbances and systemic organ dysfunction is critical. However, the advent and continued refinement of cross-sectional imaging modalities over the past two decades has led to a prominent role for diagnostic imaging in assessing acute pancreatitis. Furthermore, these cross-sectional imaging modalities have enabled the development of diagnostic and therapeutic interventional techniques in the hands of radiologists. In this article we review the diagnostic features of acute pancreatitis, the clinical staging systems, complications and the role of imaging. The role of interventional radiology techniques in the management of acute pancreatitis will be discussed as well as potential complications associated with these treatments.