Mesenteric venous thrombosis associated with protein C deficiency

An 83-year-old man had gradually worsening abdominal pain and vomiting. Laparotomy revealed segmental intestinal infarction resulting from thrombosis in the superior mesenteric vein. Necrosed intestine was resected and anastomosis was performed successfully. The patient was anticoagulated with intravenous heparin and nafamostat mesilate followed by oral aspirin. He recovered rapidly. Blood chemistry revealed protein C deficiency, while protein S and antithrombin III levels were normal. Laboratory evaluation of these proteins may help define the cause of mesenteric venous thrombosis. Received: August 14, 1998/Accepted: December 18, 1998     

Nomogram for predicting transmural bowel infarction in patients with acute superior mesenteric venous thrombosis

BACKGROUND The prognosis of acute mesenteric ischemia(AMI) caused by superior mesenteric venous thrombosis(SMVT) remains undetermined and early detection of transmural bowel infarction(TBI) is crucial. The predisposition to develop TBI is of clinical concern, which can lead to fatal sepsis with hemodynamic instability and multi-organ failure. Early resection of necrotic bowel could improve the prognosis of AMI, however, accurate prediction of TBI remains a challenge for clinicians. When determining the eligibility for explorative laparotomy, the underlying risk factors for bowel infarction should be fully evaluated.AIM To develop and externally validate a nomogram for prediction of TBI in patients with acute SMVT.METHODS Consecutive data from 207 acute SMVT patients at the Wuhan Tongji Hospital and 89 patients at the Guangzhou Nanfang Hospital between July 2005 and December 2018 were included in this study. They were grouped as training and external validation cohort. The 207 cases(training cohort) from Tongji Hospital were divided into TBI and reversible intestinal ischemia groups based on the final therapeutic outcomes. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for TBI using the training data, and a nomogram was subsequently developed. The performance of the nomogram was evaluated with respect to discrimination, calibration, and clinical usefulness in the training and external validation cohort.RESULTS Univariate and multivariate logistic regression analyses identified the following independent prognostic factors associated with TBI in the training cohort: The decreased bowel wall enhancement(OR = 6.37, P 0.001), rebound tenderness(OR = 7.14, P 0.001), serum lactate levels 2 mmol/L(OR = 3.14, P = 0.009) and previous history of deep venous thrombosis(OR = 6.37, P 0.001). Incorporating these four factors, the nomogram achieved good calibration in the training set [area under the receiver operator characteristic curve(AUC) 0.860; 95%CI: 0.771-0.925] and the external validation set(AUC 0.851; 95%CI: 0.796-0.897). The positive and negative predictive values(95%CIs) of the nomogram were calculated, resulting in positive predictive values of 54.55%(40.07%-68.29%) and 53.85%(43.66%-63.72%) and negative predictive values of 93.33%(82.14%-97.71%) and 92.24%(85.91%-95.86%) for the training and validation cohorts, respectively. Based on the nomogram, patients who had a Nomo-score of more than 90 were considered to have high risk for TBI. Decision curve analysis indicated that the nomogram was clinically useful.CONCLUSION The nomogram achieved an optimal prediction of TBI in patients with AMI. Using the model, the risk for an individual patient inclined to TBI can be assessed, thus providing a rational therapeutic choice.     

Mesenteric venous infarction in acute pancreatitis

Segmental intestinal necrosis is a rare complication of acute pancreatitis. The pathogenesis of intestinal necrosis in acute pancreatitis has previously been attributed to arterial thrombosis, but we have observed an unusual case of segmental small intestinal infarction associated with pancreatitis that could not be explained by this mechanism. In our patient, the clinical, gross, and microscopic features were compatible with mesenteric venous infarction. A search of the literature revealed three previous cases of small intestinal infarction in patients with acute pancreatitis with similar clinical and histologic findings. Mesenteric venous infarction of the colon has also been described in association with acute pancreatitis. It seems clear that mesenteric venous infarction represents an additional cause of intestinal necrosis in patients with acute pancreatitis, and may result from changes in clotting mechanisms known to be induced by acute pancreatitis.     

Outcomes and clinical characteristics of transmural intestinal necrosis in acute mesenteric ischemia

Abstract

Background: Acute mesenteric ischemia (AMI) is a rare life-threatening condition, especially for the patients with transmural intestinal necrosis (TIN). However, the optimal time for surgical intervention is controversial. As a series study, this study aimed to identify the outcomes and clinical characteristic of patients with TIN.

Methods: Clinical data of 158 patients with AMI from January 2010 to December 2017 were retrospectively analyzed in a national gastrointestinal referral center in China to confirm the outcomes and identify predictors for TIN.

Results: According to the results of pathological assessment and follow-up, 62 patients were TIN and 96 were non-TIN. Patients with TIN have a higher mortality and incidence of severe complications. The significant independent predictors for TIN were arterial lactate level (OR: 4.76 [2.29 ～ 9.89]), free intraperitoneal fluid (OR: 9.49 [2.56?～?35.24]) and pneumatosis intestinalis (OR: 7.08 [1.68?～?29.82]) in computed tomography (CT) scan imaging. The overall area under the receiver operating characteristics (ROC) curve of the model was 0.934 (95% confidence interval: 0.893?～?0.974). Using ROC curve, the cutoff value of arterial lactate level predicting the onset of TIN was 2.65?mmol/L.

Conclusions: Patients concomitant with TIN manifest a higher risk of poor prognosis. The three predictors for TIN were arterial lactate level >2.65?mmol/L, free intraperitoneal fluid and pneumatosis intestinalis. Close monitoring these predictors would help identify AMI patients developed TIN and in urgent need for bowel resection.     

Indications for surgery in severe acute pancreatitis

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Those indications that are widely accepted include:

急性肠系膜静脉血栓形成30例临床分析

目的分析急性肠系膜静脉血栓形成的临床特点和治疗。方法对我院30例急性肠系膜静脉血栓患者的临床资料进行回顾性分析,并结合文献总结急性肠系膜静脉血栓的临床特点、诊断及治疗方法。结果30例急性肠系膜静脉血栓患者,年龄19～78岁,平均年龄51．9岁。手术治疗19例,死亡7例;溶栓治疗11例,放弃治疗1例。结论腹部CT可对早期急性肠系膜静脉血栓做出正确的诊断,早期溶栓或手术治疗可以降低死亡率。     

An unreported complication of acute pancreatitis

Acute pancreatitis constitutes 3% of all admissions with abdominal pain. There are reports of osteal fat necrosis leading to periosteal reactions and osteolytic lesions following severe pancreatitis, particularly in long bones. A 54-year-old man was admitted to our hospital with acute pancretitis, who later developed spinal discitis secondary to necrotizing pancreatitis. He was treated conservatively with antibiotics and after a month he recovered completely without any neurological deficit. This case is reported for its unusual and unreported spinal complications after acute pancreatitis.     

高脂血症性急性胰腺炎与胆源性胰腺炎的临床对比分析

目的对比分析高脂血症性急性胰腺炎（hyperlipidemic acute pancreatitis,HLAP）与急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的临床特点。方法回顾性对比分析我院2005年8月～2010年8月间收治的28例HLAP和64例ABP患者的临床资料。结果 HLAP组BMI、重症患者比例、Ranson评分≥3、CT分级为D、E及APACHEII≥8分者均较ABP组高（P〈0.05）。HLAP组血清TG、GLU、UA均显著高于ABP组,而ALT、AKP、TBIL、DBIL及血AMY均显著低于ABP组（P〈0.05）。两组患者平均住院时间无统计学差异（P〉0.05）。HLAP组患者死亡率为14.3%）,显著高于ABP组的1.5%（P〈0.05）。结论与ABP组相比,HLAP组通常病情较重,多为SAP且常不伴有血淀粉酶的显著升高,且死亡率高。     

Predictors of irreversible intestinal resection in patients with acute mesenteric venous thrombosis

BACKGROUND Acute mesenteric venous thrombosis(AMVT) can cause a poor prognosis. Prompt transcatheter thrombolysis(TT) can achieve early mesenteric revascularization. However, irreversible intestinal ischemia still occurs and the mechanism is still unclear.AIM To evaluate the clinical outcomes of and to identify predictive factors for irreversible intestinal ischemia requiring surgical resection in AMVT patients treated by TT.METHODS The records of consecutive patients with AMVT treated by TT from January 2010 to October 2017 were retrospectively analyzed. We compared patients who required resection of irreversible intestinal ischemia to patients who did not require.RESULTS Among 58 patients, prompt TT was carried out 28.5 h after admission. A total of 42(72.4%) patients underwent arteriovenous combined thrombolysis, and 16(27.6%) underwent arterial thrombolysis alone. The overall 30-d mortality rate was 8.6%. Irreversible intestinal ischemia was indicated in 32(55.2%) patients, who had a higher 30-d mortality and a longer in-hospital stay than patients without resection. The significant independent predictors of irreversible intestinal ischemia were Acute Physiology and Chronic Health Evaluation(APACHE) II score(odds ratio = 2.368, 95% confidence interval: 1.047-5.357, P = 0.038) and leukocytosis(odds ratio = 2.058, 95% confidence interval: 1.085-3.903, P = 0.027).Using the receiver operating characteristic curve, the cutoff values of the APACHE II score and leukocytosis for predicting the onset of irreversible intestinal ischemia were calculated to be 8.5 and 12 × 109/L, respectively.CONCLUSION Prompt TT could achieve a favorable outcome in AMVT patients. High APACHE II score and leukocytosis can significantly predict the occurrence of irreversible intestinal ischemia. Therefore, close monitoring of these factors may help with the early identification of patients with irreversible intestinal ischemia, in whom ultimately surgical resection is required, before the initiation of TT.     

Carboxyl ester lipase in human tissues and in acute pancreatitis

Carboxyl ester lipase was purified from human pancreatic juice. Antisera were raised in rabbits and the monospecificity of the antibody was verified by immunoblotting. The enzyme was present in zymogen granules of acinar cells, in occasional duct cells, and in secretory material in normal pancreas in immunohistochemistry. Also, occasional cells in the epithelium of small intestinal villi but not the granules of Paneth cells, were stained. Decreased and evenly dispersed staining was observed in necrotic acinar cells in acute pancreatitis, whereas the reaction was intensive in plugs in acinar lumina. Interstitial staining was seen around necrotic pancreatic lobules and in areas of fat necrosis. This staining pattern is similar to that obtained with antisera against other lipolytic pancreatic proteins, but differed from that with antisera against trypsin and pancreatic secretory trypsin inhibitor. We conclude that carboxyl ester lipase behaves similarly to the other lipolytic enzymes during acute pancreatitis and that interstitial localization of secretory lipolytic enzymes is characteristic of the necrotizing inflammatory process in pancreas.     

An audit of percutaneous drainage for acute necrotic collections and walled off necrosis in patients with acute pancreatitis

Background and objectives

Percutaneous catheter drainage (PCD) is used as a first step in the management of symptomatic fluid collections in patients with acute pancreatitis (AP). We aimed to compare the outcome of patients with acute necrotic collection (ANC) and those with walled-off necrosis (WON), who had undergone PCD as a part of management of AP.

急性心肌梗死并发急性胰腺炎的相关因素分析

目的 探讨急性心肌梗死与急性胰腺炎并存的相关因素.方法 将12例急性心肌梗死与急性胰腺炎并存的患者按照入院诊断的先后顺序,分为急性心肌梗死合并急性胰腺炎组和急性胰腺炎合并急性心肌梗死组,两组均为6例.回顾分析12例患者的临床资料,比较两组患者的一般状况、临床表现及血淀粉酶、肌钙蛋白浓度和临床预后.结果 两组的临床特点均有胸闷、胸痛和（或）腹痛症状,体征方面均有腹部压痛.在急性心肌梗死合并急性胰腺炎组中,血清肌钙蛋白中位数数值比急性胰腺炎合并急性心肌梗死组高,差异有统计学意义（P=0.005）;而血清淀粉酶值中位数数值,急性心肌梗死合并急性胰腺炎组则比急性胰腺炎合并急性心肌梗死组低,差异有统计学意义（P=0.002）.两种疾病并存时临床转归不理想.结论 急性心肌梗死与急性胰腺炎并存时病情凶险,预后差.当患者有胸闷、胸痛,同时又伴有腹痛和腹部压痛等临床表现时,应警惕两种疾病并存的可能性.     

Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis

AIM:To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis(ASMVT)in patients with circumscribed peritonitis.METHODS:A retrospective review was made of the Vascular Surgery Department’s medical records to identify adult patients(≥18 years old)presenting with circumscribed peritonitis and diagnosed with ASMVT by imaging or endoscopic examination.Patients were selected from the time period between October 2009and October 2012 to assess the overall performance of a new first-line treatment policy implemented in May2011 for patients with circumscribed peritonitis,which recommends transcatheter thrombolysis with local anticoagulation and endovascular mechanical thrombectomy.Of the 25 patients selected for study inclusion,12 had undergone emergency surgical exploration(group 1)and 13 had undergone the initial catheterdirected thrombolysis(group 2).Data extracted from each patient’s records for statistical analyses included method of diagnosis,symptoms,etiology and risk factors,thrombus location,initial management,morbidity,mortality,duration and total cost of hospitalization(in Renminbi,RMB),secondary operation,total length of bowel resection,duration of and findings in follow-up,and death/survival.RESULTS:The two treatment groups showed similar rates of morbidity,30-d mortality,and 1-year survival,as well as similar demographic characteristics,etiology or risk factors,computed tomography characteristics,symptoms,findings of blood testing at admission,complications,secondary operations,and follow-up outcomes.In contrast,the patients who received the initial non-operative treatment of transcatheter thrombolysis had significantly shorter durations of admission to symptom elimination(group 1:18.25±7.69 d vs group 2:7.23±2.42 d)and hospital stay(43.00±13.77 d vs 20.46±6.59 d),and early enteral or oral nutrition restoration(20.50±5.13 d vs 8.92±1.89 d),as well as significantly less total length of bowel resection(170.83±61.27 cm vs 29.23±50.24 cm)and lower total cost(200020.4±91505.62 RMB vs 72785.6±21828.16 RMB)(P<0.05 for all).Statistical analyses suggested that initial transcatheter thrombolysis is correlated with quicker resolution of the thrombus,earlier improvement of symptoms,stimulation of collateral vessel development,reversal of intestinal ischemia,receipt of localizing bowel resection to prevent short bowel syndrome,shorter hospitalization,and lower overall cost of treatment.CONCLUSION:For ASMVT patients with circumscribed peritonitis,early diagnosis is key to survival,and nonoperative transcatheter thrombolysis is feasible and effective as an initial treatment.     

Use of antibiotics in acute pancreatitis: ten major concerns

Abstract

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15–20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3?days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.     

Profile of and risk factors for early unplanned readmissions in patients with acute necrotizing pancreatitis

IntroductionAcute necrotizing pancreatitis (ANP) complicates up to 15% of acute pancreatitis cases. ANP has historically been associated with a significant risk for readmission, but there are currently no studies exploring factors that associate with risk for unplanned, early (<30-day) readmissions in this patient population.MethodsWe performed a retrospective review of all consecutive patients presenting to hospitals in the Indiana University (IU) Health system with pancreatic necrosis between December 2016 and June 2020. Patients younger than 18 years of age, without confirmed pancreatic necrosis and those that suffered in-hospital mortality were excluded. Logistic regression was performed to identify potential predictors of early readmission in this group of patients.ResultsOne hundred and sixty-two patients met study criteria. 27.7% of the cohort was readmitted within 30-days of index discharge. The median time to readmission was 10 days (IQR 5–17 days). The most frequent reason for readmission was abdominal pain (75.6%), followed by nausea and vomiting in (35.6%). Discharge to home was associated with 93% lower odds of readmission. We found no additional clinical factors that predicted early readmission.ConclusionPatients with ANP have a significant risk for early (<30 days) readmission. Direct discharge to home, rather than short or long-term rehabilitation facilities, is associated with lower odds of early readmission. Analysis was otherwise negative for independent, clinical predictors of early unplanned readmissions in ANP.     

急性肠系膜静脉血栓形成8例临床分析

目的探讨急性肠系膜静脉血栓形成(AMVT)的诊治要点。方法回顾性分析我院1995年7月至2003年6月经手术确诊的8例AMVT的临床特点及诊治情况。结果8例术前均以急腹症就诊,疑诊AMVT2例,8例均手术后确诊。1例为肠系膜上静脉主干血栓形成,全小肠坏死,术后2d死亡。余7例部分肠系膜静脉栓塞及肠坏死,6例治愈,1例并发双下肢深静脉血栓形成。5例明确病因。结论AMVT大多数以急腹症就诊,早期腹痛明显而体征轻微是其临床特点,临床诊断较困难。对有急性弥漫性腹膜炎、可疑肠坏死和血流动力学不稳的患者应立即手术治疗。     

急性坏死性胰腺炎模型大鼠血清脂联素表达水平及意义

目的观察急性坏死性胰腺炎模型大鼠血清脂联素表达变化及与胰腺损伤程度的相关性在急性坏死性胰腺炎发病中的意义。方法40只雄性Sprague-Dawley大鼠随机分为正常对照组(CON组)8只及急性坏死性胰腺炎组(ANP组)32只。CON组剖腹后只翻动十二指肠及胰腺后关腹。ANP组逆行胰胆管内注射1.5%去氧胆酸钠制备ANP模型。术后6、12、24、48 h处死大鼠,观察胰腺组织病理改变并评分,检测血清淀粉酶、脂联素、TNF-α和IL-6水平变化。结果 ANP组大鼠胰腺病理学评分及血清淀粉酶、TNF-α、IL-6水平均较CON组升高(P<0.05),血清脂联素在发病早期下降缓慢,24 h后迅速下降,48 h较24 h显著降低(P<0.01),并与胰腺病理学评分及TNF-α水平呈高度负相关(r=-0.846、-0.789,P<0.05)。结论血清脂联素在ANP发生发展中呈现一定的变化规律,并且与胰腺严重程度呈负相关,可能在ANP的发病机制中起重要作用。     

Peritoneal lavage with aprotinin in patients with severe acute pancreatitis

Summary Conclusion Although high-dose aprotinin given intraperitoneally to patients with severe acute pancreatitis seems to inhibit activated trypsin in the peritoneal cavity, the treatment has little effect on the balance between proteases and antiproteases. Plasma levels of leukocyte proteases were high in all the patients, indicating leukocyte activation to be an important feature of the pathophysiology of severe acute pancreatitis. A surprise finding was that the patients had higher peritoneal levels of pancreatic secretory trypsin inhibitor (PSTI) after the lavage procedure. Background Although most studies have shown protease inhibitor therapy to have little or no effect on acute pancreatitis, in an earlier study we found that very high doses of the protease inhibitor aprotinin given intraperitoneally to patients with severe acute pancreatitis seemed to reduce the need of surgical treatment for pancreatic necrosis. In the present study we have further analyzed plasma and peritoneal samples from the same patients to ascertain whether the aprotinin treatment affects the balance between proteases and endogenous antiproteases. Methods In a prospective double-blind randomized multicenter trial, 48 patients with severe acute pancreatitis were treated with intraperitoneal lavage. One group (aprotinin group,n=22) was also treated with high doses (20 million KIU given over 30 h) of aprotinin intraperitoneally. The remaining 26 patients made up the control group. The protease-antiprotease balance was studied by measuring immunoreactive anionic trypsin (irAT), cationic trypsin (irCT), complexes between cationic trypsin and alpha 1-protease inhibitor (irCT-α1PI), leukocyte elastase and neutrophil proteinase 4 (NP4), as well as the endogenous protease inhibitors, pancreatic secretory trypsin inhibitor (PSTI), alpha 2-macroglobulin (α 2M), alpha 1-protease inhibitor (α 1PI), antichymotrypsin (ACHY), and secretory leukocyte protease inhibitor (SLPI). Intraperitoneal levels were studied before and after the lavage procedure, and plasma levels were followed for 21 d. Results The control group had lower plasma levels of SLPI and analysis of peritoneal fluid showed the reduction of irCT-α 1PI to be more pronounced in the aprotinin group. None of the other variables measured differed significantly between the two groups. All patients had very high levels of leukocyte elastase and NP4 both in peritoneal exudate and in plasma. Peritoneal levels of PSTI were higher after the lavage procedure in contrast to the other measured variables that all showed lower peritoneal levels after the lavage.