Incidence Of Pancreatic Necrosis Research Articles

Early Versus Delayed Enteral Feeding in Predicted Severe Acute Gallstone Pancreatitis: A Retrospective Study.

BackgroundThe optimal timing of enteral nutrition (EN) initiation in predicted severe acute gallstone pancreatitis (SAGP) and its influence on disease outcomes are not well known.MethodsWe conducted a retrospective study of patients with predicted SAGP treated with endoscopic retrograde cholangiopancreatography and EN. The patients were classified into two groups according to the timing of EN initiation after admission: within 48 h, and more than 48 h. The primary outcome was in-hospital mortality. The secondary outcomes were length of hospital stay, need for intensive care admission, need for surgical intervention, improvements in blood test results after 7-10 days of EN, incidence of pancreatic necrosis and infection, and hospital care costs. The microbiological profiles of infectious complications were also evaluated.ResultsOf the 98 patients, 31 and 67 started EN within 48 h, and more than 48 h after admission, respectively. Early EN was associated with a decrease in in-hospital mortality (0 vs. 11.9%; p=0.045), length of hospital stay (median:18 vs. 27 days; p=0.001), need for intensive care admission (3.2% vs. 20.9%; p=0.032), and hospital care costs (median:9,289 vs. 13,518 US$; p=0.007), compared to delayed EN. Moreover, early EN for 7-10 days had more beneficial effects on blood test results than delayed EN, including total protein (p=0.03) and CRP (p=0.006) levels. However, the need for surgical intervention and incidence of pancreatic necrosis did not differ between the two groups. In our study, Gram-negative bacteria were the main responsible pathogens (50.5%). Infection with multidrug-resistant organisms (MDRO) was found in 19.4% of the patients. The most common MDRO was MDR Enterococcus faecium. Early EN was not superior in reducing incidence of infected pancreatic necrosis, bacteremia, polymicrobial infection, or MDROs.ConclusionsIn patients with predicted SAGP, early EN is associated with a decrease in in-hospital mortality, length of hospital stay, need of intensive care admission, and hospital care costs, compared to delayed EN. There are no significant benefits of early EN in reducing the rate of infection-related complications. Further studies with larger sample sizes are warranted.

Impact of low-molecular-weight heparin in the treatment of moderately severe and severe acute pancreatitis; a randomized, single blind, phase 3 control trial

IntroductionAcute pancreatitis is inflammation of pancreatic parenchyma which is an emergency condition. It is classified as mild, moderately severe, and severe categories. In severe acute pancreatitis, mortality is up to 10%–30%. Pancreatic abscess increases the mortality to 40%, and infected pancreatitis carries 100% mortality without surgical drainage. Anti-coagulant, anti-inflammatory and anti-protease activities of low-molecular-weight heparin are involved in preventing pancreatic necrosis and curbing the adverse outcomes of acute pancreatitis. AimTo determine the effect of low-molecular-weight heparin on the outcome of moderately severe and severe acute pancreatitis. Materials and methodologyHospital based, single centre, randomized, single blind, phase 3 control trial. First 140 patients with moderately severe and severe acute pancreatitis admitted in hospital in the given period who met the inclusion and exclusion criteria were taken. 70 patients were placed in the control and the trial group each by simple randomization (closed envelope method). The control group received conventional treatment for pancreatitis & the trial group received 1mg/kg body weight Enoxaperin, subcutaneously, 12 hourly for seven days along with the conventional treatment.Progression of disease in Computed Tomography Severity Index and incidence of pancreatic necrosis were the main outcomes studied at the end of 7 days of treatment. Results1386 acute abdomen cases were screened, of which 269 were diagnosed with acute pancreatitis. 147 patients with acute pancreatitis met the selection criteria and 7 were dropouts. Recruitment started on April 9, 2021 and closed on December 5, 2021. Computed Tomography Severity Index progressed in 22(31.40%) patients in control group and 6(8.6%) patients in the trial group and 18(25.71%) in the control group and 4(5.71%) in the trial group showed the presence of necrosis. The differences are significant (P value is 0.001 in each). No adverse events were seen. ConclusionUse of low-molecular-weight heparin in early stage of moderately severe and severe acute pancreatitis significantly reduces the chance of disease progression and pancreatic necrosis.

English

BACKGROUND Acute pancreatitis is a very common disease and severe acute pancreatitis is life threatening and needs early identification. Current severity predicting indices in acute pancreatitis are cumbersome. There have been previous reports of low HDL cholesterol in life threatening acute pancreatitis. Previous studies in this regard were done in a single ethnicity population and needed to be validated in other ethnic groups. We wanted to estimate the proportion of pancreatic necrosis among the patients with acute pancreatitis attending Government Medical College, Thiruvananthapuram. We also wanted to compare the mean HDL values in those who developed pancreatic necrosis and those who didn’t develop pancreatic necrosis and evaluate the association between HDL value measured 48 – 72 hours of onset of symptoms and pancreatic necrosis. METHODS This was a prospective observational study conducted among 271 patients diagnosed with acute pancreatitis in Government Medical College Hospital, Thiruvananthapuram. Consecutive sampling method was used. RESULTS There were 42 cases of pancreatic necrosis out of 271 cases. The mean HDL of those patients with pancreatic necrosis was found to be less than those without necrosis (P < 0.001). Mean HDL value among those having pancreatic necrosis was 17.7 whereas those without necrosis was 34.9. CONCLUSIONS Proportion of pancreatic necrosis was 15.5 %. The mean HDL measured at 48 hours of symptom onset among the necrotising pancreatitis patients was significantly low when compared to the non-necrotic group (17.7 vs 34.9). All the patients with pancreatic necrosis had their HDL less than 40. Thus, an inference that low HDL at 48 hours of symptom onset was associated with higher incidence of pancreatic necrosis and severe pancreatitis could be made. KEYWORDS Pancreatitis, HDL, Pancreatic Necrosis

Acute pancreatitis: predictors of mortality, pancreatic necrosis and intervention.

Several predictive scoring systems are used in the prognostication of acute pancreatitis (AP). However, the quantity of evidence of these prognostic systems in the Indian population remains sparse. The aim of our study was to evaluate the usefulness of such prognostic scores to predict mortality, incidence of pancreatic necrosis and intervention in AP. This was an observational study of patients diagnosed with AP between June 2012 and November 2013 in a tertiary referral center in India. Vital signs, biochemical tests and CT-findings were recorded to identify SIRS, Ranson's score and CT-severity index at diagnosis. Chi square test was used to compare incidence of mortality, pancreatic necrosis, and intervention between mild versus severe acute pancreatitis groups. A total of 100 patients with AP were treated during out study period. Ranson's score more than 7 and presence of pancreatic necrosis were significantly associated with increased mortality (p <0.05). SIRS, CTSI score more than 7, inotropic support, and complications were more frequently associated with patients with necrosis. Prophylactic antibiotics did not decrease mortality, but decreased intervention rate (p <0.05). Presence of systemic inflammatory response syndrome (SIRS), Ranson's score > 7, necrosis, inotropic support and presence of complications were associated with a greater rate of interventions including surgery and percutaneous procedures (p <0.05). We validate SIRS, Ranson's, and CTSI score as prognostic markers for AP in the Indian population. These predictors, when used in combination, can direct early monitoring and aggressive management in order to decrease mortality associated with severe AP.

Clinical value of sequential organ failure assessment score in evaluating organ function in acute pancreatitis

Objective To compare the clinical value of sequential organ failure assessment (SOFA) score and revised Marshall score in evaluating organ function in acute pancreatitis (AP). Methods From January 2013 to December 2017, at the Department of Gastroenterology of The First Affiliated Hospital of Nanchang University, the clinical data of 3 957 hospitalized AP patients were collected through the AP electronic database. AP was diagnosed and the severity of the disease was classified according to the revised Atlanta classification criteria. Organ function was evaluated by modified Marshall score and SOFA score. The correlation between SOFA score and mortality, pancreatic necrosis were analyzed. Chi-square test and Spearman correlation analysis were performed for statistical analysis. Results The incidences of circulatory failure and renal failure determined by the SOFA score were higher than those of the modified Marshall score (4.80%, 190/3 957 vs. 3.03%, 120/3 957; 10.11%, 400/3 957 vs. 6.44%, 255/3 957), and the differences were statistically significant (χ2=1 599.54 and 2 237.19, both P<0.01). Two score systems were consistent in determining the incidence of respiratory failure, which were 32.22% (1 275/3 957). The incidences of persistent circulatory failure (≥48 h) and persistent renal failure (≥48 h) determined by the SOFA score were higher than those of the modified Marshall score (1.64%, 65/3 957 vs. 0.76%, 30/3 957; 4.78%, 189/3 957 vs. 3.69%, 146/3 957), and the differences were statistically significant (χ2=1 458.37 and 2 398.01, both P<0.01). The incidence of persistent respiratory failure (≥48 h) was same determined by two score systems, which were 10.24% (405/3 957). The proportion of patients with severe AP determined by SOFA score was higher than that of the modified Marshall score (25.30%, 1 001/3 957 vs. 18.83%, 745/3 957), and the difference was statistically significant (χ2=718.216, P<0.01). The results of Spearman correlation analysis showed that SOFA total score was positively correlated with the overall mortality and the incidence of pancreatic necrosis (correlation coefficients r were 0.540 and 0.211, respectively), and the differences were statistically significant (both P<0.01). Conclusion SOFA score can comprehensively evaluate organ function in AP and is an important approach in determining prognosis. Key words: Sequential organ failure assessment score; Acute pancreatitis; Revised Marshall score; Organ function

19 Outcomes of Acute Necrotizing Pancreatitis and Associated Fluid Collections in Cannabis Users

INTRODUCTION: Acute Pancreatitis can be complicated by pancreatic necrosis and or pancreatic/peripancreatic fluid collections. The effects of cannabis and the incidence of necrosis and/or pancreatic/peripancreatic fluid collections have not been yet studied. We sought to investigate if cannabis users had less incidence of pancreatic necrosis and/or pancreatic/peripancreatic fluid collections and to ascertain the clinical effects cannabis use has on severity and outcomes in this group of patients. METHODS: We performed a retrospective cohort study of all consecutive patients admitted with a first episode of acute pancreatitis at a large tertiary referral center in Chicago, IL from 01/01/2012 to 04/30/2018. Acute pancreatitis diagnosis and severity were identified as per the Revised Atlanta Classification. Presence of pancreatic necrosis or pancreatic/peripancreatic fluid was stablished by radiologic imaging or histopathologic evaluation. Use of cannabis was identified via recorded history and/or urine toxicology. A multivariate logistic regression model was constructed using STATA software version 13 (STATA Corp LLC College Station Texas, USA). RESULTS: Five hundred and nineteen patients were included, from which 107 (20.6%) were cannabis users (CU). A total of 69 patients developed acute necrotizing pancreatitis; 58 (84%) were non-cannabis users (N-CU) and 11 (16%) were CU A total of 109 patients with moderate-severe acute pancreatitis developed pancreatic/peripancreatic fluid collections, 92 (84.4%) were NCU and 17 (16.6%) were CU. Acute necrotizing pancreatitis outcomes: CU were more likely to have persistent SIRS (18.2% vs. 12.1%) and to require ICU (63.6% vs. 43.1%), they were also less likely to have Infected necrosis (9.1% vs. 51.7%), bacteremia (18.2% vs. 31%), to require debridement of necrosis (9.1% vs. 32.8%). CU with any pancreatic/peripancreatic fluid collection were more likely to have AKI (47.1% vs. 26.1%). CONCLUSION: Cannabis users with acute necrotizing pancreatitis or fluid collection are more likely to have persistent SIRS, AKI and require ICU. However, they're less likely to have infected necrosis/fluid collections, bacteremia and to require pancreatic/peripancreatic fluid debridement. This is a pioneer study to investigate the clinical impact of cannabis use in acute pancreatitis, including outcomes and severity in patients with pancreatic necrosis and pancreatic/peripancreatic fluid collections.

Large triglyceride-rich lipoproteins in hypertriglyceridemia are associated with the severity of acute pancreatitis in experimental mice

Hypertriglyceridemia severity is linked to acute pancreatitis prognosis, but it remains unknown why a portion of severe hypertriglyceridemia patients do not develop severe acute pancreatitis. To investigate whether hypertriglyceridemia subtypes affect acute pancreatitis progression, we analyzed two genetically modified hypertriglyceridemia mouse models—namely, glycosylphosphatidylinositol high-density lipoprotein binding protein 1 knockout (Gpihbp1−/−) and apolipoprotein C3 transgenic (ApoC3-tg) mice. Acute pancreatitis was induced by 10 intraperitoneal caerulein injections. Biochemical assays and pathological analysis were performed for the severity evaluation of acute pancreatitis. Plasma triglyceride-rich lipoproteins (TRLs), including chylomicrons and very low-density lipoprotein (VLDL), were collected via ultracentrifugation to evaluate their cytotoxic effects on primary pancreatic acinar cells (PACs). We found that the particle sizes of Gpihbp1−/− TRLs were larger than ApoC3-tg TRLs. Severe pancreatic injury with large areas of pancreatic necrosis in the entire lobule was induced in Gpihbp1−/− mice when plasma triglyceride levels were greater than 2000 mg/dL. However, ApoC3-tg mice with the same triglyceride levels did not develop large areas of pancreatic necrosis, even upon the administration of poloxamer 407 to further increase triglyceride levels. Meanwhile, in the acute pancreatitis model, free fatty acids (FFAs) in the pancreas of Gpihbp1−/− mice were greater than in ApoC3-tg mice. TRLs from Gpihbp1−/− mice released more FFAs and were more toxic to PACs than those from ApoC3-tg mice. Chylomicrons from patients showed the same effects on PACs as TRLs from Gpihbp1−/− mice. Gpihbp1−/− mice with triglyceride levels below 2000 mg/dL had milder pancreatic injury and less incidence of pancreatic necrosis than those with triglyceride levels above 2000 mg/dL, similar to Gpihbp1−/−mice with triglyceride levels above 2000 mg/dL but with fenofibrate administration. These findings demonstrated that hypertriglyceridemia subtypes with large TRL particles could affect acute pancreatitis progression and that chylomicrons showed more cytotoxicity than VLDL by releasing more FFAs.

Morbidity and Mortality of ERCP-induced Severe Acute Pancreatitis

Background/Aims: There are scant data on outcomes for ERCP induced severe acute pancreatitis (ESAP). In large series of acute pancreatitis (AP) patients ERCP- induced pancreatitis has been reported to have higher morbidity and mortality compared to other forms of AP. We compared clinical outcomes of ESAP with those of other forms of severe acute pancreatitis (SAP). Methods: Sixteen patients with ESAP and 196 patients with SAP due to other causes were admitted to Mayo Clinic Hospitals between 1992 and 2001. Medical records were reviewed to compare their length of stay, ICU stay, morbidity (incidence of organ failure, sepsis, or local complications including pancreatic and peri-pancreatic necrosis, pseudocysts, abscess, infection and need for surgery) and mortality. Results: Of the 16 patients with ESAP, 13 had undergone therapeutic and 3 had diagnostic ERCP. On comparison of ESAP with other forms of SAP, the median length of hospital stay (24 vs 30 days), need for ICU care (50% vs 66%), and median length of ICU stay (1 vs 4 days) were similar. The incidence of organ failure (33% vs 54%), sepsis (31% vs 36%) and DIC (6% in both groups) were also similar in the two groups. Incidence of pancreatic necrosis (19% vs 29%), pseudocyst (31% vs 44%), and abscess (13% vs 26%) was not different in the two groups. Infection (+ve blood or pancreatic fluid culture) occurred in 8/16 ESAP patients compared to 68/196 with other forms of SAP (p=ns). Candida albicans infection occurred in 1/8 ESAP versus 18/68 with other forms of SAP (p=ns). Surgery was performed in 63% of ESAP vs 67% of SAP due to other causes. Mortality was similar in the two groups (25% vs 16%). Conclusions: The morbidity and mortality of ERCP-induced SAP are similar to those of SAP due to other causes.