Resolution Of Acute Pancreatitis Research Articles

Elevated Serum Fibroblast Growth Factor 21 in Humans with Acute Pancreatitis

BackgroundThe metabolic regulator Fibroblast Growth Factor 21 (FGF21) is highly expressed in the acinar pancreas, but its role in pancreatic function is obscure. It appears to play a protective role in acute experimental pancreatitis in mice. The aim of this study was to define an association between FGF21 and the course and resolution of acute pancreatitis in humans.Methods and Principal FindingsTwenty five subjects with acute pancreatitis admitted from May to September 2012 to the Beth Israel Deaconess Medical Center (BIDMC) were analyzed. Serial serum samples were collected throughout hospitalization and analyzed for FGF21 levels by ELISA. Twenty healthy subjects sampled three times over a four week period were used as controls. We found that, in patients with pancreatitis, serum FGF21 rises significantly and peaks four to six days after the maximum lipase level, before slowly declining. Maximum FGF21 levels were significantly greater than baseline levels for acute pancreatitis subjects (1733 vs. 638 pg/mL, P = 0.003). This maximum value was significantly greater than the highest value observed for our control subjects (1733 vs. 322 pg/mL, P = 0.0002). The ratio of active to total FGF21 did not change during the course of the disease (42.5% vs. 44.4%, P = 0.58). Fold increases in FGF21 were significantly greater in acute pancreatitis subjects than the fold difference seen in healthy subjects (4.7 vs. 2.0, P = 0.01). Higher fold changes were also seen in severe compared to mild pancreatitis (18.2 vs. 4.4, P = 0.01). The timing of maximum FGF21 levels correlated with day of successful return to oral intake (R2 = 0.21, P = 0.04).ConclusionsOur results demonstrate that serum FGF21 rises significantly in humans with acute pancreatitis. The pancreas may be contributing to increased FGF21 levels following injury and FGF21 may play a role in the recovery process.

Concurrent Treatment of Acute Pancreatitis and Multiple Visceral Artery Aneurysms Using Endovascular Techniques

Multiple aneurysms involving the celiac axis are extremely rare. Celiac artery aneurysms account for only 4% of all visceral aneurysms with 40% having concomitant aneurysms such as gastroduodenal artery (GDA) aneurysms. Development of a GDA aneurysm is associated with pancreatitis. If a GDA aneurysm ruptures, traditional repair is through open surgical techniques with significant morbidity and mortality as up to 50% occur in the setting of chronic pancreatitis. However, a ruptured GDA aneurysm causing pancreatitis has not been described previously. We report a case of successful endovascular treatment of a ruptured GDA aneurysm and concomitant celiac artery aneurysm leading to the resolution of acute pancreatitis.

Anomalous Pancreaticobiliary Junction in a Western Population Undergoing ERCP

Purpose: Anomalous pancreaticobiliary junction (APBJ) is a rare union of the biliary and pancreatic ducts (PD), which is associated with pancreaticobiliary malignancy (PBM). We characterize our experience with this condition in a Western population. Methods: We retrospectively reviewed an ERCP database of 7467 pts at Maine Medical Center from January 1991-February 2011. Clinical, surgical and pathological data was reviewed. Results: APBJ was found in 26 pts (F:18, M:8, median age 48 yrs, range 4-71 yrs, 23 Caucasians, 1 African-American, 1 Hispanic, 1 Asian, 0.35% incidence in ERCP over 20 yrs). 7 pts had type I union, 17 pts had type II union. Type I choledochal cyst (CC) was present in 19 pts. 22 pts presented with abdominal pain, 5 with jaundice, 14 with acute pancreatitis (AP), and 3 with chronic pancreatitis (CP). The average time of onset of symptoms to diagnosis (dx) was 15.8 mos (range 0-78 mos). Pancreas divisum was found in 4/26 pts (complete n = 2, incomplete n = 2). Sphincterotomy (ES) was performed in 22 pts. CBD stones were extracted from 5 pts. Of pts presenting with pancreatitis, ES was performed in 14/14 with resolution of AP in 100%. Of 5 pts with recurrent AP, 2 resulted from proteinaceous debris in remnant CC stumps, 1 had pancreas divisum, 1 had chronic pancreatitis with PD stricture, and 1 had not undergone prior ES. PBM was present in 5 pts (gallbladder cancer n = 1, stage I; cholangiocarcinoma (CCa) n = 4, 3 stage IV, 1 stage II). Of the 4 pts with CCa, 2 pts who had prior biliary surgery during childhood presented with stage IV disease (1 with choledochoduodenostomy and partial CC resection 59 yrs prior to dx, 1 with cholecystojejunostomy without CC resection 48 yrs prior). 2/5 pts with jaundice presented with PBM. 17 pts underwent cholecystectomy. Of the 19 pts with type I CC, 14 pts underwent CC resection (10/14 with complete resection through the pancreatic head). 7/10 pts with complete CC resection had preoperative PD stent placed which assisted with CC dissection through the pancreatic head. Excluding the pts with biliary surgery during childhood, no surgical patients developed PBM (average follow up 3.8 yrs, range 0-16.6 yrs). Conclusion: APBJ is rare in a Western population. Definitive therapy for recurrent AP involves ES, and potentially full CC resection. Avoidance of PBM necessitates resection of biliary mucosa, including gallbladder and choledochus. Preoperative PD stenting appears to assist with complete CC resection.

Overlapping Presence of Macroamylasemia and Hyperamylasemia in Acute Pancreatitis

Overlapping Presence of Macroamylasemia and Hyperamylasemia in Acute Pancreatitis

DIC secondary to acute pancreatitis

Various hematological abnormalities including fall in serial values of hemoglobin or hematocrit, coagulation factor abnormalities, leukocytosis, acute hemolytic anemia, thrombocytopenia, and thrombotic thrombocytopenic purpura or hemolytic uremic syndrome have been reported in patients with acute pancreatitis. Similarly, abnormalities of blood coagulation factors consistent with disseminated intravascular coagulopathy (DIC) have also been noticed in patients with pancreatitis. We report a case of a 33-year-old female with acute pancreatitis who presented with one episode of epistaxis and abnormal prothrombin time and partial prothrombin time. Coagulation work-up revealed thrombin time 24.3 s fibrinogen 110 mg/dl, D-dimers >1 and < 2, and fibrin degradation products >22. Pancultures did not show any evidence of infection. The patient maintained a normal renal and mental status during her illness. Her D-dimers continued to decrease with resolution of acute pancreatitis as evidenced by decreased abdominal pain, relief of nausea, control of vomiting, and decrease in serum amylase and lipase levels. This case report suggests that coagulation abnormalities are encountered in patients with acute pancreatitis. It is hypothesized that such hemostatic abnormalities may be related to early intravascular consumption of coagulation factors secondary to circulating pancreatic enzymes, particularly trypsin, or secondary to vascular injury. Recognition of these hematological complications including DIC is paramount. Physicians caring for these patients should be aware of such a complication of acute pancreatitis.

Levels of leukocyte proteases in plasma and peritoneal exudate in severe, acute pancreatitis.

Levels of leukocyte elastase and neutrophil protease 4 (NP4(3)) in plasma and peritoneal exudate were studied in 25 patients with severe, acute pancreatitis. Pancreatitis was diagnosed from the clinical picture and an increased serum amylase level. The diagnosis was verified by computerized tomography, ultrasound, and findings at operation or autopsy. Peritoneal exudate on admission contained high concentrations of leukocyte elastase (6100 +/- 2000 micrograms/l) and NP4(3) (2310 +/- 900 micrograms/l). High initial levels were found also in plasma, which contained 659 +/- 110 micrograms/l of leukocyte elastase and 254 +/- 33 micrograms/l of NP4(3). The levels in plasma were still increased 3 weeks after the acute attack, also in the absence of complications, indicating that the resolution of acute pancreatitis is a protracted process. Plasma levels of both leukocyte proteases were persistently increased in patients with pancreatic abscess, in contrast to the gradual decrease seen in patients with a pseudocyst or uncomplicated recovery. The levels were increased already before the abscess was diagnosed clinically, which indicates that determinations of leukocyte elastase and NP4(3) may be helpful in detecting this complication. A pathophysiologic role for leukocyte proteases in the development of severe, acute pancreatitis should be considered.

Biliary pancreatitis: Clinical presentation and surgical management

The presentation, surgical management, and clinical outcome in 153 patients with biliary pancreatitis has been reviewed. Only 37 percent of our patients demonstrated any of Ranson's 11 prognostic signs of severe pancreatitis, and only 3 percent had 3 or more signs. Fourteen patients underwent emergency operation within 48 hours of admission, 108 underwent briefly delayed operation during the same hospitalization, and 31 were discharged and scheduled for elective cholecystectomy 6 weeks after admission. The biliary pancreatitis grew worse in 7 of 114 patients during initial medical management and required emergency operation, and 81 percent underwent elective surgery within 10 days of admission. When patients were discharged before cholecystectomy, the recurrence rate of acute biliary pancreatitis that required emergency readmission was unacceptably high (61 percent). There was no statistical difference in total number of hospital days, number of intensive care unit days, or mortality between the three groups. Our study suggests that emergency operation with decompression of the ampulla of Vater is unnecessary in patients with biliary pancreatitis, and that briefly delayed operation during the same hospitalization can be performed safely after resolution of acute pancreatitis.