Cases Of Severe Acute Pancreatitis Research Articles

A comparative evaluation of different scores in predicting severity and outcome in acute pancreatitis

Background: Acute pancreatitis (AP) is an inflammatory condition usually caused by alcohol or gallstones. Our goal was to prospectively compare the diagnostic efficacy of the Acute Physiology & Chronic Health Evaluation (APACHE) II, the Bedside Index of Severity in Acute Pancreatitis (BISAP), the Ranson's score & the Modified Glasgow Score (MGS) in determining the severity & outcome of Acute pancreatitis in a tertiary care facility in central India. Methods: Between December 2020 & December 2022, this prospective observational study was done in rural area of Wardha district. 110 subjects were included, and the diagnosis of acute pancreatitis was done using Atlanta criteria. APACHE II, MGS, Ranson score on admission, Ranson score 48 hours after admission & BISAP were used to evaluate each subject. The reciever operating curve was used to measure the specificity, sensitivity, NPV, PPV, diagnostic accuracy, area under the curve (AUC) & these scoring methods were then prospectively compared. Results: When a cut-off based on the literature was used, the APACHE II score could accurately diagnose severe cases of AP (n=110) in 69 patients, BISAP in 68 patients, MGS in 49, Ranson score on admission in 48 patients & after 48 hours in 48 patients. This study showed that Ranson score 48 hours after admission had a AUC (0.991), Ranson score at admission (AUC 0.989) & Modified Glasgow Scale (AUC 0.6486) had fair accuracy as compared to APACHE II (AUC 0.974) & BISAP (AUC 0.896) for determining the level of severity among AP patients based on ROC curves. Conclusion: To predict the severity of AP, the Ranson score after 48 hours showed the highest NPV, PPV, sensitivity, specificity, and diagnostic accuracy of all the scoring methods tested. The BISAP score had the highest specificity, sensitivity, PPV& NPV for determining the outcome of AP.

Extracellular Vesicle ITGAM and ITGB2 Mediate Severe Acute Pancreatitis-Related Acute Lung Injury.

Integrins expressed on extracellular vesicles (EVs) secreted by various cancers are reported to mediate the organotropism of these EVs. Our previous experiment found that pancreatic tissue of mice with severe cases of acute pancreatitis (SAP) overexpresses several integrins and that serum EVs of these mice (SAP-EVs) can mediate acute lung injury (ALI). It is unclear if SAP-EV express integrins that can promote their accumulation in the lung to promote ALI. Here, we report that SAP-EV overexpress several integrins and that preincubation of SAP-EV with the integrin antagonist peptide HYD-1 markedly attenuates their pulmonary inflammation and disrupt the pulmonary microvascular endothelial cell (PMVEC) barrier. Further, we report that injecting SAP mice with EVs engineered to overexpress two of these integrins (ITGAM and ITGB2) can attenuate the pulmonary accumulation of pancreas-derived EVs and similarly decrease pulmonary inflammation and disruption of the endothelial cell barrier. Based on these findings, we propose that pancreatic EVs can mediate ALI in SAP patients and that this injury response could be attenuated by administering EVs that overexpress ITGAM and/or ITGB2, which is worthy of further study due to the lack of effective therapies for SAP-induced ALI.

Experience of double plasma purification in 603 patients from a single center in Shanghai, China.

To summarize the clinical experiences with double plasma purification (DPP). Using Plasauto iQ automatic blood purification system, model KM-9000 for DPP. A total of 603 patients with different entity undergoing 811 purification procedures were included in this study. The most common purification modes were dual filtration plasma plasmapheresis (DFPP). Hyperlipidemia was the lead entity, 423 patients with hyperlipidemia performed DFPP, and two cases of severe acute pancreatitis caused by extremely high triglyceride levels completely recovered after two consecutive DFPP treatments. DFPP combined with immunosuppressants tended to decrease independent HD and reduced HD frequency in 53 patients with antineutrophil cytoplasmic antibody-associated vasculitis. Two patients developed hypotensive or hypoglycemia episodes, respectively, during purification procedures. DPP is rapid for the treatment of patients with severe hyperlipidemia and acute pancreatitis caused by severely high triglyceride levels. For those who are intolerant to statins，DPP provides another treatment choice. DPP process is safe.

S1933 Acute Pancreatitis Attributed to COVID-19: An Unusual Infectious Etiology

Introduction: COVID-19 can affect multiple organs and has various presentations, including respiratory symptoms and fever being the most common. Gastrointestinal symptoms can be reported in up to 25% of patients, with diarrhea, nausea, and emesis the usual presentation. However, abdominal pain is less than 6.8% of cases, and of those, only 27% presented with Acute Pancreatitis (AP). Here we present a case of severe AP with multiorgan involvement as the initial presentation of COVID19. Case Description/Methods: Case of a 19 y/o Female with a medical history of Obesity class I arrived at the ED with recurrent emesis and altered mental status. Symptoms began around four days prior with 6-7 episodes of non-bloody, non-bilious emesis, fatigue, subjective fever, and decreased oral intake, followed by acute onset of diffuse abdominal pain. Upon arrival, the patient was found encephalopathic with dry oral mucosa, tachycardic and tachypneic. Laboratories were remarkable for lipase 2483, amylase 382, LDH 315, ALP 219 U/L, sodium 155 mEq/L, creatinine 1.33 mg/dL, bicarbonate < 9 mmol/L, pH 7.0, pO2Sat 96%, hematocrit 51.8%, WBC 14.9 cells/L, glucose 774 mg/dL, and COVID 19 PCR positive. Abdominal US and CT with no findings suggestive of gallstones or intraabdominal pathology. Aggressive intravenous fluid, insulin, broad-spectrum antibiotics, bicarbonate replacement, analgesia, and antiemetics were implemented. Hospitalization was complicated as the patient did not tolerate PO intake, and the high anion gap metabolic acidosis was difficult to close for several days. After almost two weeks in the ICU, the patient was discharged home without apparent pancreatitis or COVID-19 repercussions. Discussion: Our case did not have any risk factors for AP, and extensive investigations did not reveal a clear etiology. Viral, bacterial, fungal, and parasitic infections are less common causes of AP. There are limited data on COVID-19 and pancreatitis; however, recent studies suggest a higher mortality rate with a 20% increased chance of dying and worse clinical outcomes. The mechanism of pancreatic injury is not well understood, but there is a link between COVID-19 and the precipitation of autoimmune and systemic diseases. Our case is an example of severe pancreatic injury with multiorgan involvement in mild symptomatic COVID 19.

Roles of soluble TAM receptors, ligands for these receptors, and shedding enzymes in patients with acute pancreatitis

The goal of the study was to measure the plasma levels of soluble TAM receptors (sTAMRs: Tyro3, Axl and Mer), growth arrest-specific 6 (Gas6), free-PROS1 (Protein S), and C4bp-protein and two disintegrin metallopeptidase domains (ADAM 10 and 17) in patients with acute pancreatitis (AP). The subjects were 56 patients, including 14 cases of severe AP and 42 cases of mild AP, and 20 healthy normal controls. Plasma levels of the three sTAMRs, Gas6, free PROS1 and C4bp-protein, and two ADAMs were measured using ELISA kits. The levels of the sTAMRs and ADAM10 and 17 increased markedly with greater severity of AP. Three sTAMRs increase rate became the order of sTyro3, sMer and sAxl, while ADAM10 was higher than ADAM17. The platelet count and PROS1 significantly decreased in AP but there are differences between C4bp-protein, but these are not significant. sTAMRs levels increased in the early stage in almost all AP patients, but then gradually normalized. However, sTAMRs in non-survivors increased again in the late stage. The fluctuations of ligands (Gas6 and free-PROS1) levels in AP patients showed progress like three sTAMRs. The correlation coefficients of sTAMRs with ligands were stronger for free-PROS1 in non-survivors and patients with severe AP, whereas Gas6 was more strongly correlated with sTAMRs in patients with mild AP. Marked increases of sTAMRs and ADAMs were found with increased severity of AP. Gas6 and free-PROS1 in the TAM system may have complementary roles in local and systemic lesions, respectively.

Necrotizing pancreatitis complicated by retroperitoneal emphysema: two case reports.

BackgroundEmphysematous pancreatitis is acute pancreatitis associated with emphysema based on imaging studies and has been considered a subtype of necrotizing pancreatitis. Although some recent studies have reported the successful use of conservative treatment, it is still considered a serious condition. Computed tomography (CT) scan is useful in identifying emphysema associated with acute pancreatitis; however, whether the presence of emphysema correlates with the severity of pancreatitis remains controversial. In this study, we managed two cases of severe acute pancreatitis complicated with retroperitoneal emphysema successfully by treatment with lavage and drainage.Case presentationCase 1: A 76-year-old man was referred to our hospital after being diagnosed with acute pancreatitis. At post-admission, his abdominal symptoms worsened, and a repeat CT scan revealed increased retroperitoneal gas. Due to the high risk for gastrointestinal tract perforation, emergent laparotomy was performed. Fat necrosis was observed on the anterior surface of the pancreas, and a diagnosis of acute necrotizing pancreatitis with retroperitoneal emphysema was made. Thus, retroperitoneal drainage was performed. Case 2: A 50-year-old woman developed anaphylactic shock during the induction of general anesthesia for lumbar spine surgery, and peritoneal irritation symptoms and hypotension occurred on the same day. Contrast-enhanced CT scan showed necrotic changes in the pancreatic body and emphysema surrounding the pancreas. Therefore, she was diagnosed with acute necrotizing pancreatitis with retroperitoneal emphysema, and retroperitoneal cavity lavage and drainage were performed. In the second case, the intraperitoneal abscess occurred postoperatively, requiring time for drainage treatment. Both patients showed no significant postoperative course problems and were discharged on postoperative days 18 and 108, respectively.ConclusionAcute pancreatitis with emphysema from the acute phase highly indicates severe necrotizing pancreatitis. Surgical drainage should be chosen without hesitation in necrotizing pancreatitis with emphysema from early onset.

Acid ceramidase targeting pyruvate kinase affected trypsinogen activation in acute pancreatitis

BackgroundAcute pancreatitis is the sudden inflammation of the pancreas. Severe cases of acute pancreatitis are potentially fatal and have no specific treatment available. Premature trypsinogen activation could initiate acute pancreatitis. However, the mechanism underlying premature trypsinogen activation is not fully understood.MethodsIn this research, a primary pancreatic acinar cell or mouse acute pancreatitis model was constructed. The effect of acid ceramidase (ASAH1), which is responsible for sphingosine production, was investigated in trypsinogen activation in vitro and in vivo. Meanwhile, the proteins regulating ASAH1 or binding to sphingosine were also detected by co-immunoprecipitation followed by mass spectrometry.ResultsThe results showed that ASAH1 increased in acute pancreatitis. Increased ASAH1 promoted the activation of trypsinogen and cathepsin B. On the contrary, ASAH1 downregulation inhibited trypsinogen and cathepsin B. Meanwhile, ASAH1 regulated the activity of trypsin and cathepsin B through sphingosine. Additionally, E3 ligase Mind bomb homolog 1 (MIB1) decreased in acute pancreatitis resulting in the decreased binding between MIB1 and ASAH1. Exogenous MIB1 diminished the elevation in trypsin activity induced by acute pancreatitis inducer. ASAH1 increased owing to the inhibition of the proteasome degradation by MIB1. In acute pancreatitis, sphingosine was found to bind to pyruvate kinase. Pyruvate kinase activation could reduce trypsinogen activation and mitochondrial reactive oxygen species (ROS) production induced by sphingosine.ConclusionsIn conclusion, during the process of acute pancreatitis, MIB1 downregulation led to ASAH1 upregulation, resulting in pyruvate kinase inhibition, followed by trypsinogen activation.

CRAC channel inhibitors in pancreatic pathologies.

CRAC channel inhibitors in pancreatic pathologies.

Acute Pancreatitis in Japan: Comparison of Before and After Revision of the Clinical Guidelines.

Cases of acute pancreatitis (AP) are increasing worldwide, and mortality remains high in severe cases. In 2015, the Japanese guidelines for the management of AP were revised. We aimed to clarify the clinical practice of AP in Japan and its trend during the revision of the guidelines using a Japanese nationwide administrative database. We retrospectively analyzed 102,119 patients with AP who were hospitalized between April 2014 and March 2018. The study period was divided into the first period (the time before the revision: fiscal years 2014 and 2015) and second period (after the revision: 2016 and 2017). Severe cases of AP accounted for 27.7% of total cases. The in-hospital mortality in severe cases was 5.7%. The mortality within 14 days of admission improved from 3.2% in the first period to 2.6% in the second period (P = 0.022). Referred patients had more severe diseases and a higher mortality. The mortality in patients who underwent endoscopic ultrasound-guided fistuloplasty for local complications (11.6%) was lower than that in patients who underwent percutaneous drainage (23.4%) or AP surgery (22.6%) (P < 0.001). We clarified the clinical practice of AP including the improved mortality after the revision of the guidelines.

152 Improving Imaging in Acute Pancreatitis

Abstract Aim In the UK it is not a current practice to perform early (&amp;lt; 3 days) CT for detection and staging of severe cases of acute pancreatitis. Findings of pancreatic necrosis, fat stranding and intraperitoneal fluid should be included in the CT scan report as they are important prognostic factors. Furthermore, radiological facilities should be available to permit US examination of the gallbladder &amp;lt;24 hours of the diagnosis. The aim was to meet 95% for all standards. Method Retrospective baseline data were obtained for 83 patients presented with acute pancreatitis between January 2020 and February 2021. Several interventions were implemented including educational posters, emails and lectures to general surgeons and radiologists. Re-auditing was conducted between May and August 2021 to measure the effectiveness of these interventions. Results Baseline showed low compliance to standards, and 62% of presented patients underwent early CT (&amp;lt; 3 days). Only 78% received US scan within 24 hours of admission. Second cycle showed increased adherence to NICE guidelines with 56% of patients had CT scan in optimal timing. Reports of CT scans showed minimal improvement in terms of including the prognostic factors. US examination of gall bladder improved with 83% of patients diagnosed with acute pancreatitis. Conclusions Early CT may underestimate final severity of acute pancreatitis. Low adherence to guidelines was noticed in the first audit cycle which was increased after the interventions. Further interventions and auditing will be needed.

A Case of Severe Acute Pancreatitis Caused by Afferent Loop Syndrome after Gastrectomy with Billroth-II Reconstruction

A Case of Severe Acute Pancreatitis Caused by Afferent Loop Syndrome after Gastrectomy with Billroth-II Reconstruction

S1551 A Rolling Stone: A Rare Case of Severe Acute Pancreatitis Caused by Obstructive Suppurative Pancreatic Ductitis

S1551 A Rolling Stone: A Rare Case of Severe Acute Pancreatitis Caused by Obstructive Suppurative Pancreatic Ductitis

Fluid resuscitation via colon alleviates systemic inflammation in rats with early-stage severe acute pancreatitis

Fluid resuscitation via colon (FRVC) is a complementary therapeutic procedure for early-stage cases of severe acute pancreatitis (SAP). The expression of intestinal dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin (DC-SIGN) regulates systemic inflammation. This study aimed to investigate the effect of FRVC on the expression of DC-SIGN in the colon tissue of SAP rats and its effect on the early response of systemic inflammatory and multiple organ injury. SAP was induced in rats via retrograde injection of sodium taurocholate into the biliopancreatic duct. DC-SIGN expression of appeared in the proximal and distal colon. Histological characteristics and inflammatory cytokines were examined to compare the effect of FRVC and intravenous fluid resuscitation (IVFR). The results showed that DC-SIGN expression in the proximal colon increased in a time-dependent manner in the early-stage of SAP rats. FRVC inhibited DC-SIGN expression in the proximal colon. Both FRVC and IVFR alleviated histological injuries of the pancreas and colon. However, FRVC had an advantage over IVFR in alleviating lung injury and reducing serum TNF-α, IL-6 and LPS. These results suggest that FRVC treatment might help suppress systemic inflammation and prevent subsequent organ failure in early-stage SAP rats likely through inhibiting DC-SIGN expression in the proximal colon.

A serendipitous case report of acute pancreatitis complicated by pseudocyst in a patient with COVID-19

Acute pancreatitis is a common gastrointestinal disease, most frequently requiring acute hospitalization. During SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) pandemic, the etiologic agent of COVID-19, several studies described the involvement of other tissues besides the respiratory tract, such as the gastrointestinal tract. In pancreas, ACE-2 receptor is expressed in exocrine glands and islets, both being targets for the virus and subsequent pancreatic injury. There are few articles which report pancreatic injury in COVID-19 patients but most of them do not report acute pancreatitis. Diagnosing acute pancreatitis in the setting of COVID-19 pandemic is challenging and requires ruling out all other potential causes of pancreatitis. Herein we report a rare case of severe acute pancreatitis.

The value of a dual-energy spectral CT quantitative analysis technique in acute pancreatitis

To explore the value of dual-energy spectral computed tomography (DESCT) in evaluating the clinical severity of acute pancreatitis. Seventy patients with acute pancreatitis (AP) confirmed by clinical examination were included in this study. All patients underwent unenhanced/double-phase enhanced CT in spectral imaging mode. Iodine concentration and normalised iodine concentration (NIC) were measured retrospectively with a spectral imaging viewer (GSI Viewer). All data were analysed by analysis of variance. Receiver operating characteristic (ROC) curves were constructed to determine the optimal threshold for predicting the clinical severity of AP. Seventy patients were included in the study comprising 30 mild, 22 moderate, and 18 severe cases of AP. The CT attenuation value, iodine concentration, and NIC were decreased with increasing clinical severity. Moreover, there were significant differences between the mild group and the severe group (p<0.05), as well as between the moderate group and the severe group (p<0.05). The area under the ROC curve AUC of each value was larger in arterial phase than in portal venous phase. The most sensitive value between the mild and severe groups in AP was the NIC (arterial phase: 0.19±0.06; portal venous phase: 0.45±0.09). DESCT can provide multiple parameters to determine the severity of AP.

Hypertriglyceridemia induced recurrent pancreatitis case

ABSTRACT: Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP). It is caused by disorders in lipoprotein metabolism due to primary or secondary causes. Metabolic syndrome is also an important factor contributing to the development of HTG. The primary treatment goal in severe HTG is to restore triglyceride levels within normal ranges which can be achieved with lipid lowering drugs mainly fenofibrates, fluid replacement, intravenous insulin infusion and/ or plasmapheresis treatments. Strict diet restricted from fat and simple sugars, exercise and weight control also contribute to HTG control in long term follow up. In this report, a case of severe AP triggered by HTG with other metabolic syndrome components like type 2 diabetes mellitus and obesity is presented.

A Prospective Study to Evaluate BISAP Score in Acute Pancreatitis

Introduction: Acute Pancreatitis (AP) is among leading cause of acute abdomen in the study institution. There is a need of simple criteria to stratify patients in Emergency Department. The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is one such score. Aim: This study evaluates the BISAP score to predict organ failure, pancreatic necrosis and moderately severe/severe AP in tertiary health care center in India and promote its use. Materials and Methods: This prospective observational study was conducted on 50 consecutive patients diagnosed as AP from May 2019 to April 2020 and admitted in Emergency Department of DMC Hospital, Ludhiana, India. BISAP score was calculated based on data obtained within 24 hours of hospitalisation. Severity of AP was defined according to the Revised Atlanta Classification, 2012. Organ failure was defined using the Modified Marshall scoring system. Data was expressed in terms of median, frequencies (number of cases) and relative frequencies (percentages); range; mean±Standard Deviation (±SD). All statistical calculations were done in Microsoft Windows Statistical Package for the Social Science (SPSS) version 21.0. Results: The leading cause of AP in present study is gall stones, with maximum 26 (52%) cases. Second most common cause is alcohol with 11 (22%) cases. Systemic Inflammatory Response Syndrome (SIRS) is the most common component of BISAP score, present in 47 (94%) cases. Pancreatic necrosis present in 12 (24%) cases. Incidence of pancreatic necrosis rises at score ≥3 which is statistically significant (p-value- 0.008). Transient organ failure was present in 14 (28%) cases, persistent organ failure was present in 9 (18%) cases and 27 (54%) cases had no organ failure. At score ≥3, there is increased risk of organ failure and it is statistically significant (p-value ≤0.001). There are 27 (54%) mild, 14 (28%) moderately severe and 9 (18%) severe cases of AP. At score ≥3, there is increased risk of moderately severe and severe pancreatitis and it is statistically significant (p-value ≤0.001). Conclusion: There is statistically significant trend of increasing incidence of organ failure, pancreatic necrosis and moderately severe/severe AP at BISAP score ≥3. Thus, BISAP score is simple yet accurate scoring system to improve early risk stratification in AP.

An autopsy case of severe acute pancreatitis induced by administration of pazopanib following nivolumab

Drug-induced pancreatitis is often mild to moderate in severity, but severe and even fatal cases can occur. Here, we report a 74-year-old woman undergoing chemotherapy for recurrent renal cell carcinoma, who presented with abdominal pain after administration of pazopanib following nivolumab and was diagnosed with severe acute pancreatitis. Administration of methylprednisolone and conservative treatment were initiated, but clinical findings and laboratory tests rapidly worsened. When she died, an autopsy was performed. The autopsy findings suggested the possibility of pancreatitis as immune-related adverse events. To the best of our knowledge, no fatal cases of acute pancreatitis due to nivolumab or pazopanib have been reported. We considered that the effects of nivolumab were sustained in the pancreas, and pazopanib administration might have worsened the toxicity.

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.