Pancreatic Necrosis In Patients Research Articles

Peak Serum Creatinine as a Biomarker of Pancreatic Necrosis in Acute Pancreatitis: A Cross-Sectional Study

Pancreatitis is the inflammation of the pancreas. Pancreatitis can result in pancreatic necrosis which may lead to significant morbidity and mortality. It is possible to predict pancreatic necrosis and organ dysfunction using many biochemical indicators and markers. Peak serum creatinine has been identified as one of such useful markers to predict pancreatic necrosis. Objective: To find the diagnostic accuracy of elevated peak serum creatinine as a predictor of pancreatic necrosis in patients with acute pancreatitis taking the contrast-enhanced computed tomogram scan (CECT) as the gold standard and to establish the degree of agreement between the two clinical tests. Methods: A cross-sectional, analytical study that was carried out at the Department of Surgery, Benazir Bhutto Hospital, Rawalpindi from January 2020 to January 2023. 150 patients diagnosed as having pancreatitis were enrolled in the study. Peak serum creatinine at 48 hours > 1.8 mg/dl was labeled as a predictor of pancreatic necrosis. Contrast-enhanced computed tomogram scan was done within 96 hours of admission. The pancreatic necrosis suggested by raised serum creatinine was confirmed by CECT. The diagnostic accuracy of peak serum creatinine and the degree of agreement between the two modalities was calculated. The Kappa coefficient was used to calculate the strength of agreement. Results: The results show that Peak serum creatinine has a sensitivity of 45.5%, specificity of 97.35%, PPV of 85.0 %, NPV of 93.8 %, and accuracy of 84.6%. This study found that the degree of agreement between raised peak serum creatinine levels and CECT to predict pancreatic necrosis was 84.7% with a “Kappa coefficient” of 0.51. Consequently, the null hypothesis was rejected in light of these findings. Conclusions: It was concluded that elevated serum creatinine (SCr >1.8 mg/dl) at 48 h of admission can be used as a predictor of pancreatic necrosis in patients with acute pancreatitis.

Predictive value of PASS score combined with NLR and CRP for infected pancreatic necrosis in patients with severe acute pancreatitis

To investigate the predictive value of pancreatitis activity scoring system (PASS) combined with Neutrophil to lymphocyte ratio (NLR) and C-reactive protein (CRP) for infected pancreatic necrosis (IPN) in patients with severe acute pancreatitis (SAP). Clinical data of SAP patients admitted to the First Affiliated Hospital of Zhengzhou University from January 2020 to January 2023 were retrospectively collected, including basic information, vital signs at admission, first laboratory indexes within 48 hours of admission. The PASS scores at admission and 24, 48 and 72 hours after admission were calculated. According to the diagnostic criteria of IPN, the patients were divided into the non-IPN group and the IPN group, and the independent risk factors of SAP complicating IPN were determined by using univariate analysis and multifactorial Logistic regression. The receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of NLR, CRP, and PASS score, alone and in combination for IPN in patients with SAP. A total of 149 SAP patients were enrolled, including 102 in the non-IPN group and 47 in the IPN group. The differences in PASS score at each time point, NLR, CRP, procalcitonin (PCT), blood urea nitrogen, blood chloride, and days of hospitalization between the two groups were statistically significant. Multifactorial Logistic regression analysis showed that 72 hours admission PASS score [odds ratio (OR) = 1.034, 95% confidence interval (95%CI) was 1.005-1.065, P = 0.022], NLR (OR = 1.284, 95%CI was 1.139-1.447, P = 0.000), and CRP (OR = 1.015, 95%CI was 1.006-1.023, P = 0.001) were independent risk factors for IPN in patients with SAP. ROC curve analysis showed that the area under the ROC curve (AUC) of the PASS score at 72 hours of admission, NLR, and CRP alone in predicting IPN in SAP patients were 0.828, 0.771, and 0.701, respectively. The AUC of NLR combined with CRP, PASS combined with NLR, and PASS combined with CRP were 0.818, 0.895, and 0.874, respectively. The combination of PASS score at 72 hours after admission, NLR, and CRP had a better predictive ability for IPN in patients with SAP (AUC = 0.922, 95%CI was 0.877-0.967), and the sensitivity was 72.3% when the cut-off value was 0.539. The predictive value of the PASS score at 72 hours after admission, NLR and CRP in combination for IPN in SAP patients is better than that of the combination of each two and individual detection and has better test efficacy.

Correlation between abdominal perfusion pressure and timing of infection of pancreatic necrosis in patients with acute severe pancreatitis

Correlation between abdominal perfusion pressure and timing of infection of pancreatic necrosis in patients with acute severe pancreatitis

Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study.

Background and Objectives: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. Materials and Methods: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (<30%, 30–50%, >50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. Results: The study included 83 patients (75.9% males (n = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (n = 42, 51%). Positive blood culture (n = 14 (87.5%)), multiple organ dysfunction syndrome (n = 17 (73.9%)) and incidences of respiratory failure (n = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (p < 0.05). Patients with >50% of necrosis were significantly (p < 0.05) more often diagnosed with moderately severe (n = 24 (41.4%)) and severe (n = 18 (72%)) AP. The number of surgical interventions (n = 18 (72%)) and ultrasound-guided interventions (n = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (n = 11 (64.7%)) and infected pancreatic necrosis (n = 19 (57.6%)) was significantly higher (p < 0.05). Conclusions: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.

The Effects of the Fat Distribution of Body, Skeletal Muscle Mass and Muscle Quality on Acute Pancreatitis Severity: A Retrospective Cross-Sectional Study.

We aim to investigate a possible relationship between acute pancreatitis (AP) and body fat and muscle parameters in computed tomography (CT). Computed tomography images of 107 patients with AP were scored in terms of AP severity using the modified CT severity index. Muscle mass, muscle mass index, visceral and subcutaneous adipose tissue area, multifidus muscle/fat attenuation ratio, total psoas index (TPI) and Hounsfield units average calculation (HUAC) values were performed. Total psoas index and HUAC of mild AP cases were significantly higher than those with moderate and severe AP. The TPI of patients with severe pancreatic necrosis were found to be significantly lower than those without necrosis. Hounsfield units average calculation of cases without necrosis were significantly higher than those with severe necrosis in the pancreas. Our study indicated that lower volume and density of psoas muscle associated with worse CT severity score and larger pancreatic necrosis in patients with AP.

The association of parameters of body composition and laboratory markers with the severity of hypertriglyceridemia-induced pancreatitis

BackgroundHypertriglyceridemia has arisen as the third leading cause of acute pancreatitis. This study aimed at exploring the association between the severity of hypertriglyceridemia-induced pancreatitis (HTGP) and computed tomography (CT)-based body composition parameters and laboratory markers.MethodsLaboratory and clinical parameters were collected from 242 patients with HTGP between 2017 and 2020. Severity of HTGP was evaluated by original or modified CT severity index. Body composition parameters such as area and radiodensity of muscle, subcutaneous adipose tissue and visceral adipose tissue were calculated by CT at the level of third lumbar vertebra. Parameters were compared between mild and moderately severe to severe HTGP. Uni-variate and multi-variate Logistic regression analyses were employed to assess the risk factors of the severity of HTGP.ResultsSeventy patients (28.9%) presented with mild HTGP. Body mass index, waist circumference and all CT-based body composition parameters differed between male and female patients. None was associated with the severity of HTGP, neither in males nor in females. Receiver operating characteristic curves showed that areas under the curves of apolipoprotein A-I and albumin to predict the severity of HTGP were 0.786 and 0.759, respectively (all P < 0.001). Uni-variate and further multi-variate Logistic regression analysis confirmed that low serum albumin (< 35 g/L, P = 0.004, OR = 3.362, 95%CI = 1.492–8.823) and apolipoprotein A-I (< 1.1 g/L, P < 0.001, OR = 5.126, 95%CI = 2.348–11.195), as well as high C-reactive protein (> 90 mg/L, P = 0.005, OR = 3.061, 95%CI = 1.407–6.659) and lipase (P = 0.033, OR = 2.283, 95%CI = 1.070–4.873) were risk factors of moderately severe to severe HTGP. Levels of albumin, apolipoprotein A-I, C-reactive protein and lipase were also associated with the length of hospital stay (all P < 0.05). Besides, low serum albumin, low-density lipoprotein cholesterol and high radiodensity of subcutaneous adipose tissue were significant risk factors of pancreatic necrosis in patients with HTGP (all P < 0.05).ConclusionsLow serum albumin and apolipoprotein A-I, and high C-reactive protein and lipase upon admission were associated with a more severe type of HTGP and longer hospital stay for these patients. Albumin and apolipoprotein A-I may serve as novel biomarkers for the severity of HTGP. However, none of the body composition parameters was associated with the severity of HTGP.

ROLE OF INTRA-ABDOMINAL PRESSURE IN PREDICTING OUTCOME IN ACUTE SEVERE PANCREATITIS

Background mortality in patients with severe acute pancreatitis (SAP) remains high. Some of these patients develop increased intra-abdominal pressure (IAP) which may contribute to organ dysfunction. The aims of this study was to evaluate intra-abdominal pressure as a marker of severity in severe acute pancreatitis and to evaluate the relationship between intra-abdominal pressure and development of complications like SIRS, organ failure, pancreatic necrosis in patients with severe acute pancreatitis.

Percutaneous debridement and washout of walled-off abdominalabscess and necrosis by the use of flexible endoscopy:an attractive clinical option when transluminal approaches are unsafe or not possible.

Background and AimsWalled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series.MethodsThe authors present a 23-patient retrospective case series of PEN with standard-sized endoscopes. The series includes 12 patients from a previously published analysis in 2016 and 11 additional patients from 2013 to 2018. A representative case illustrates the described technique in a patient with severe acute pancreatitis complicated by multisystem organ failure who required immediate drainage of a pancreatic fluid collection and placement of a percutaneous drain into the collection for decompression. The drain was serially upsized to 28F, and its tract was used for PEN.ResultsA total of 23 patients have undergone PEN at our institution. On average, the size of the pancreatic fluid collection was 11.6 cm in cross-sectional diameter. Of those 23 patients, 11 presented with symptoms of severe disease. The median time from onset of symptoms to PEN was 84 days. The median number of procedures per patient was 2.1. The median time to complete resolution of symptoms and fluid collections was 67 days. In total, resolution was reached in 22 of 23 patients. Two patients died of unrelated causes.ConclusionPEN is a minimally invasive and effective treatment approach to walled-off pancreatic necrosis in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. This case series demonstrates the efficacy and safety of this approach. A randomized prospective trial would be warranted to validate these results.

Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis

ObjectiveIn patients with pancreatitis, early persisting organ failure is believed to be the most important cause of mortality. This study investigates the relation between the timing (onset and duration) of...

Microbiological spectrum of infected pancreatic necrosis in patients requiring drainage after failure of systemic antibiotics

Microbiological spectrum of infected pancreatic necrosis in patients requiring drainage after failure of systemic antibiotics

Utility of the portal venous phase for diagnosing pancreatic necrosis in acute pancreatitis using the CT severity index.

The purpose of the study was to evaluate the value of portal venous phase (PVP) images in the diagnosis of pancreatic necrosis in patients with acute pancreatitis using computed tomography severity index (CTSI). This retrospective study was approved by our Institutional Review Board, and written informed consent was waived. Dynamic contrast-enhanced CT images, with the pancreatic parenchymal phase (PPP) and the PVP, were obtained from 56 consecutive patients with acute pancreatitis. Two radiologists reviewed two sets of images, namely PPP images alone (image set A) and combined PPP and PVP images (image set B) to evaluate the CTSI. Cases were categorized as necrotizing pancreatitis if ensuing walled-off necrosis formation was identified 4weeks after onset of symptoms. The relationship between pancreatic necrosis and CTSI was compared between image sets A and B. Logistic regression analysis was performed to evaluate the significance of clinical and radiological factors associated with the diagnosis of pancreatic necrosis. Pancreatic necrosis was confirmed in 14 out of 56 (25%) patients. The area under the receiver-operating-characteristic curve (AUC) for the diagnosis of pancreatic necrosis was 0.70 and 0.78 for image sets A and B, respectively. The AUC for image set B was significantly greater than that for image set A (P = 0.0002). Logistic regression analysis demonstrated that among clinical and radiological factors tested, CTSI for image set B was independently correlated with pancreatic necrosis (P = 0.025). Combined PPP and PVP images significantly improved the diagnostic accuracy of pancreatic necrosis following acute pancreatitis.

Short article: Presence, extent and location of pancreatic necrosis are independent of aetiology in acute pancreatitis.

The most common aetiologies of acute pancreatitis (AP) are gallstones, alcohol and idiopathic. The impact of the aetiology of AP on the extent and morphology of pancreatic and extrapancreatic necrosis (EXPN) has not been clearly established. The aim of the present study was to assess the influence of aetiology on the presence and location of pancreatic necrosis in patients with AP. We carried out a post-hoc analysis of a previously established multicentre cohort of patients with AP in whom a computed tomography was available for review. Clinical data were obtained from the medical records. All computed tomographies were revised by the same expert radiologist. The impact of aetiology on pancreatic and EXPN was calculated. In total, 159 patients with necrotizing pancreatitis were identified from a cohort of 285 patients. The most frequent aetiologies were biliary (105 patients, 37%), followed by alcohol (102 patients, 36%) and other aetiologies including idiopathic (78 patients, 27%). No relationship was found between the aetiology and the presence of pancreatic necrosis, EXPN, location of pancreatic necrosis or presence of collections. We found no association between the aetiology of AP and the presence, extent and anatomical location of pancreatic necrosis.

Pancreatic Pseudocysts and Parenchymal Necrosis in Patients With Autoimmune Pancreatitis: A Systematic Review

Introduction: Autoimmune Pancreatitis (AIP) is being increasingly recognized as a cause of acute pancreatitis (AP). The resulting potential complications of AP such as pancreatic pseudocysts (PC) and parenchymal necrosis and their natural history and management are unknown in patients with AIP. The aim of this systematic review was to examine the prevalence of the AP complications of PC and pancreatic necrosis in patients with AIP as well as their characteristics, management and outcomes. Methods: A systematic search using PubMed/Medline, Embase, Scopus, and Cochrane was performed without language or year limitations to October 1, 2016 with a medical reference librarian. Search terms were “Autoimmune pancreatitis”, “pancreatic pseudocyst”, “acute fluid collection” and “pancreatic necrosis” with all permutations. AIP was defined according to international guidelines. The search yielded 271 results. 17 case reports dating from 2004 to 2015 were included in this systematic review. Results: 12/17 (70.6%) patients were men, with a mean age of 54.82 ± 10.97 years (Range 26-75 years). In 8/17 cases, the PC were noted concurrently with the AIP diagnosis, while in the other half, the PC appeared several months or even years after the initial AIP diagnosis. In 10/17 cases, the PC appeared on imaging as solitary, while in the remaining 7 there were multiple PC. The location of the PC was variable, being present in any segment of the pancreas. PC ranged in size from small (3cm) in 13 cases. 9cm was the maximal diameter reported. 6/17 (35%) cases had a normal pancreatic duct on imaging, while 9/17 (53%) had a narrowed/stenotic pancreatic duct. 14/17 cases received steroid therapy (4/4 small, and 10/13 large PC). All 4 small PC responded completely to steroid therapy, while only 4 of 10 (40%) with large PC treated with steroids had response. 9 of the 13 cases of large PC eventually went on to undergo endoscopic or surgical interventions. None of the 17 cases had pancreatic necrosis. Conclusion: The development of PC in AIP is a rare phenomenon with only 17 cases reported. PC can be single or multiple with variable size and location. Small PC all responded to steroid therapy. Conversely, large PC had poor response to steroid therapy, and required endoscopic or surgical drainage. AIP has not been reported to be associated with development of pancreatic necrosis.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals.

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals. Retrospective analysis of collected database of patients (n=18; age 40.94±8.43years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals. Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3±0.79 and time to resolution was 4.4±1.3weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2weeks. EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

Tu1506 Endoscopic Ultrasound Guided Transmural Drainage of Walled off Pancreatic Necrosis in Patients With Portal Hypertension and Intra Abdominal Collaterals

Tu1506 Endoscopic Ultrasound Guided Transmural Drainage of Walled off Pancreatic Necrosis in Patients With Portal Hypertension and Intra Abdominal Collaterals

Prevention and treatment of post-traumatic pancreatic necrosis in patients with blunt abdominal trauma

High incidence of necrotic and suppurative complications is feature of acute post-traumatic pancreatitis. Severe trauma of the pancreas and post-traumatic pancreatitis lead to depressurization of ductal system that requires adequate drainage of damaged area and retroperitoneal fat. 95 patients in group 1 received standardized treatment. The victims of the 2nd group (44 patients) were treated using immunoreactive therapy (roncoleukin) and octreotide (the dose depended on the severity of pancreatitis) at early stages. The efficacy of treatment was assessed based on clinical, laboratory and instrumental parameters. Regardless severity of pancreatic injury overall mortality in groups 1 and 2 was 41% and 20.5% respectively. The main causes of adverse outcomes are severe destructive pancreatitis, postnecrotic suppurative complications. Adequacy rather radicalism of surgery should be preferred for blunt pancreatic trauma management. Minimally invasive surgical techniques and new methods of biological hemostasis may be applied. Timely use of anti-enzymatic and immunoactive therapy reduces the risk of severe post-traumatic pancreatitis, suppurative complications and improves outcomes in patients with blunt pancreatic trauma.

INTRAARTERIAL REGIONAL INFUSION TRACT IN THE DIAGNOSIS AND TREATMENT OF ACUTE PANCREATITIS

The study used the results of the examination and treatment of 41 patients with acute pancreatitis who underwent endovascular catheterization of the celiac trunk, followed by intra-regional perfusion of the pancreas. The clinical results of intra-regional perfusion of the pancreas showed efficacy in the prevention of septic complications, progression of pancreatic necrosis in patients with aseptic forms of severe pancreatitis. Create intraarterial infusion tract allows multislice spiral computed tomography celiacography in order to increase the information content ray imaging zones destruction of the pancreas.

Heme Oxygenase-1 Gene Promoter Polymorphism Is Associated With the Development of Necrotizing Acute Pancreatitis

Acute pancreatitis is a severe and frequently life-threatening disease, which can lead to pancreatic necrosis, acute lung injury, systemic inflammatory response syndrome, and other complications. In this study, we hypothesized that the expression of heme oxygenase-1 determined by the number of guanidinium thiocyanate (GT) repeats can influence the occurrence of acute pancreatitis. Patients with acute pancreatitis (n = 131) and age- and sex-matched healthy controls (n = 108) were studied. The polymerase chain reaction products were analyzed by ABI 3130 genetic analyzer and the exact size of the polymerase chain reaction products was determined by GeneMapper software. A short allele was defined as containing 27 GT repeats or fewer, whereas a long allele was more than 27 repeats. The subjects were categorized into 3 groups on the basis of the genotype results: 1 short and 1 long, 2 short, and 2 long alleles (L/L). Patients with necrotizing disease more frequently were carriers of LL genotype compared with those who had edematous acute pancreatitis. Furthermore, logistic regression analysis revealed that the presence of L/L allele type doubles the risk for developing pancreatic necrosis in patients with acute pancreatitis. The polymorphism of the GT repeats in the heme oxygenase-1 promoter region may be a risk factor for developing severe and necrotizing acute pancreatitis.

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Predictors of severe and critical acute pancreatitis: A systematic review

Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination. We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria. The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48h of admission, and blood urea nitrogen and Japanese Severity Score after 48h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin. Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48h of admission.