Clinical outcomes of acute pancreatitis in patients with cirrhosis

BackgroundAP outcomes in cirrhotic patients have not yet been studied. We aim to investigate the outcomes of cirrhotics patients with acute pancreatitis.MethodsThe National Inpatient Sample (NIS) database (2003–2013) was queried for patients with a discharge diagnosis of AP and liver cirrhosis. Cirrhosis was further classified as compensated and decompensated using the validated Baveno IV criteria. Primary outcome was inpatient mortality. The analysis was adjusted for age, gender, race, Charlson comorbidity index (CCI), median income quartile, and hospital characteristics.ResultsOver 2.8 million patients with acute pancreatitis were analyzed. Cirrhosis prevalence was 2.8% (80,093). Both compensated and decompensated cirrhosis subjects had significantly higher mortality. Highest odds ratios (OR) were: inpatient mortality (OR 3.4, P < 0.001), Shock (OR 1.5, P = 0.02), Ileus (OR: 1.3, p = 0.02, ARDS (OR 1.2, p = 0.03), upper endoscopy performed (OR 2.0, p < 0.001), blood transfusions (OR 3.1, p < 0.001), gastrointestinal bleed (OR 5.5, p < 0.001), sepsis (OR 1.3, p = 0.005), portal vein thrombosis (PVT) (OR 7.2, p < 0.001), acute cholecystitis (OR 1.3, p < 0.001). Interestingly, cirrhosis patients had lower hospital length of stay, (OR 0.16, p < 0.001), AKI (OR 0.93, p = 0.06), myocardial infarction (OR 0.31, p < 0.001), SIRS (OR 0.62, p < 0.001), parenteral nutrition requirement (OR 0.84, p = 0.002). Decompensated cirrhosis had higher inflation-adjusted hospital charges (+$3896.60; p < 0.001).ConclusionAP patients with cirrhosis have higher inpatient mortality, but it is unlikely to be due to AP severity as patients had lower incidence of SIRS and AKI. Higher mortality is possibly related to complications of cirrhosis and portal hypertension itself such as GI bleed, shock, PVT, AC and sepsis.     

Original research: Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

Background and aimAcute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.MethodsThis is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005–2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.ResultsIn our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.ConclusionIn this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.     

Low-grade inflammation for predicting severe acute pancreatitis in patients with hypertriglyceridemic acute pancreatitis

Objectives

We aimed to evaluate the association between low-grade inflammation (LGI) and the severity of hypertriglyceridemic acute pancreatitis (HTG-AP).

Methods

We retrospectively reviewed 311 patients with HTG-AP who were admitted to the Department of Gastroenterology, Fujian Provincial Hospital between April 2012 and March 2021. Inpatient medical and radiological records were reviewed to collect the clinical manifestations, disease severity, and comorbidities. C-reactive protein (CRP) level, white blood cell (WBC) count, platelet (PLT) count, and neutrophil-to-lymphocyte ratio (NLR) were considered LGI components and were combined to calculate a standardized LGI score. The association between the LGI score and the severity of HTG-AP was analyzed using univariate and multivariate logistic regression analyses.

Results

Of the 311 patients with HTG-AP, 47 (15.1%) had mild acute pancreatitis (MAP), 184 (59.2%) had moderately severe acute pancreatitis (MSAP), and 80 (25.7%) had severe acute pancreatitis (SAP), respectively. Patients with MSAP and SAP had a higher LGI score than those with MAP (1.50 vs −6.00, P < 0.001). Univariate logistic regression analysis revealed that patients with LGI scores in the fourth quartile were more likely to have MSAP and SAP (odds ratio [OR] 21.925, 95% confidence interval [CI] 5.014–95.867, P < 0.001). The multivariate logistic regression analysis confirmed that low calcium (OR 0.105, 95% CI 0.011–0.969, P = 0.047) and high LGI score (OR 1.253, 95% CI 1.066–1.473, P = 0.006) were associated with MSAP and SAP. When predicting the severity of acute pancreatitis, the LGI score had the highest area under the receiver operating characteristic (ROC) curve (0.7737) compared to its individual components.

Conclusion

An elevated LGI score was associated with a higher risk of SAP in patients with HTG-AP.     

重症急性胰腺炎当前应关注的问题

<正>在重症急性胰腺炎治疗发展史上,不同时期会有不同问题被关注,这并不是疾病本质有什么变化,而是专科医师对其认识在逐步加深,正如一个覆盖着纱巾的少女,在纱巾被揭开的过程中她的容貌渐渐展现在人们的面前,其实,这并非是美丽少女有什么变化,只是纱巾被揭开的程度不同而已。在两百年以前的Senn及Moynihan时代,治疗急性胰腺炎     

Prevalence and outcome of fungal infection in patients with severe acute pancreatitis

Background and Aim:  To study the prevalence of risk factors and outcome of fungal infections in patients with severe acute pancreatitis.
Methods:  Fifty consecutive patients with severe acute pancreatitis were investigated for evidence of fungal infection by weekly culture of body fluids and aspirate from pancreatic/peripancreatic tissue and samples collected at necrosectomy. All patients were managed as per a standard protocol. Patients with documented fungal infection were treated with intravenous amphotericin or fluconazole. Data were analyzed using SPSS software (version 13), and risk factors for fungal infection and mortality were determined.
Results:  Fungal infection was documented in 18 (36%) of 50 patients with Candida albicans (the commonest species). The incidence of fungal infection steadily increased with increasing duration of hospital stay. Those with fungal infection more often had evidence of respiratory failure ( P  = 0.031) and hypotension ( P  = 0.031) at admission, prolonged hospital stay > 4 weeks ( P  = 0.034), longer duration of antibiotics ( P  = 0.003), received total parenteral nutrition ( P  = 0.005), and required mechanical ventilation ( P  = 0.001) in contrast to those without fungal infection. The logistic regression analysis found the independent risk factors for fungal infection to be antibiotic therapy for > 4 weeks and hypotension at hospitalization. Of the 18 patients with fungal infection, 13 were administered intravenous antifungals; eight of these patients survived, while the five who did not receive antifungals died.
Conclusion:  Fungal infection was detected in 36% of our patients. The independent risk factors associated with it were hypotension at hospitalization and prolonged antibiotic therapy. Antifungal therapy improved their chances of survival.     

复发性急性胰腺炎42例临床分析

目的探讨复发性急性胰腺炎的病因及诊治。方法回顾性分析42例复发性急性胰腺炎的病因及诊治情况。结果 42例复发病例中,胆源性25例,特发性9例,乙醇性6例,高脂血症、胰腺肿瘤各1例。42例均先行内科保守治疗,其中中转手术治疗14例(均治愈,愈后无复发);28例坚持内科治疗,愈后再次复发9例。本组死亡4例(手术、非手术各2例)。结论急性胰腺炎愈后复发的病因复杂,与疾病及多种药物使用有关,最常见的病因为胆石症、酗酒和暴饮暴食及特发性胰腺炎等有关。明确病因,积极恰当治疗,可减少复发性急性胰腺炎的发生。     

Immunosuppression in patients with severe acute pancreatitis

Background In severe acute pancreatitis (SAP), immunologic impairment in the early phase may be linked to subsequent infectious complications. In this study, immunologic alterations in patients with SAP were analyzed, and immunologic parameters related to infectious complications were clarified. Methods A total of 101 patients with SAP were analyzed retrospectively. Various immunologic parameters on admission were analyzed and compared between the infection group and noninfection group during SAP. Furthermore, chronologic change in the lymphocyte count was investigated, and its utility for predicting infection was compared with conventional scoring systems. Results Serum immunoglobulin G (IgG), serum IgM, lymphokine-activated killer cell activity, and natural killer cell activity were low, and the incidence of abnormally low values was 50.0%, 65.0%, 45.5%, and 42.4%, respectively. Serum complement factor 3 was significantly negatively correlated with the APACHE II score. The lymphocyte count was decreased below the normal range, and was significantly negatively correlated with the APACHE II score. CD4-, CD8-, and CD20-positive lymphocyte counts were below the normal range, and CD4- and CD8-positive lymphocyte counts were significantly lower in the infection group. The lymphocyte count on day 14 after admission was significantly lower in the infection group and was more useful for predicting infection than conventional scoring systems. Conclusions Immunosuppression occurs from the early phase in SAP, and quantitative impairment of lymphocytes, mainly T lymphocytes, may be closely related to infectious complications during SAP. CD4- and CD8-positive lymphocyte counts on admission and the lymphocyte count on day 14 after admission may be useful for predicting infection.     

Using faecal elastase-1 to screen for chronic pancreatitis in patients admitted with acute pancreatitis

Background: Patients presenting with acute pancreatitis may have co-existing chronic pancreatitis, the accurate diagnosis of which would potentially guide appropriate management. Gold standard tests are often invasive, costly or time-consuming, but the faecal elastase-1 assay has been shown to be comparatively accurate for moderate and severe exocrine deficiency. This study aimed to evaluate fecal elastase-1 concentration [FE-1] against clinical criteria for chronicity in an acute setting. Patients and methods: [FE-1] was performed on patients admitted with acute onset of epigastric pain and a serum lipase at least three times the upper limit of normal. Clinical diagnosis of chronic pancreatitis was defined by the presence of specific clinical, pathological or radiological criteria. A [FE-1] value of <200 µg/g was similarly considered indicative of chronic exocrine insufficiency. Thus a 2×2 table comparing [FE-1] and clinical diagnosis was constructed. Results: After exclusion of liquid stool specimens, 105 stool specimens from 87 patients were suitable for [FE-1] determination. [FE-1] was evaluated against the clinical diagnosis of chronic pancreatitis, initially for the whole sample, and then after exclusion of cases of moderate and severe acute pancreatitis (Ranson score >2). The latter analysis, based on an exocrine insufficiency threshold of 200 µg/g, yielded a sensitivity of 79.5%, specificity of 98.0%, positive predictive value of 96.9% and negative predictive value of 86.0%. Conclusion: [FE-1] is an accurate screening tool for underlying chronic exocrine insufficiency when taken in the course of a hospital admission for mild acute pancreatitis.     

Epidemic enterocolitis possibly as a result of Norwalk virus infection presenting as ischemic colitis

Ischemic colitis usually presents as an isolated event, and clustering seldom occurs. Although a majority of instances of colonic ischemia have no clearly identifiable cause, many kinds of predisposing factors for the occurrence of ischemic colitis are pointed out. These include high age, generalized atherosclerosis, impaired cardiac function, hypovolemia, hypotension, colonoscopy, obstructing colonic cancer, coagulopathies and use of vasoconstrictors or contraceptives. However, infectious viral enterocolitis has not been regarded as a predisposing factor for colonic ischemia. We present here two cases of epidemic enterocolitis presenting as ischemic colitis that occurred almost simultaneously in two compromized long‐term patients in Noda Hospital, Chiba Prefecture. At the time, viral enterocolitis due to Norwalk virus infection was epidemic in Japan, including in the region of the hospital. It is likely that epidemic enterocolitis induced strong gut peristalsis and caused colonic spasm that mediated colonic ischemia. Indeed, both patients were elderly and had prominent signs of atherosclerosis, and one patient suffered from diabetes mellitus. Notably, the physician who performed the rectosigmoidoscopy in the two patients presented with enterocolitis 1 day after the procedure. This indicates that occupational transmission of epidemic enterocolitis can occur in medical staff during endoscopy procedures.     

Detailed fluid resuscitation profiles in patients with severe acute pancreatitis

Background and aim

Appropriate and timely initial fluid resuscitation in acute pancreatitis (AP) is critical. The aim of this retrospective study was to evaluate fluid therapy on an hour-by-hour basis in relation to standard indices of adequate resuscitation during AP.

Methods

Emergency room shock charts, fluid balance sheets and intensive care (ICU) charts for all patients with AP admitted to ICU in a large acute hospital were examined. Vital signs, clinical course and fluid administered during the first 72 h after admission were tabulated against urine output, central venous pressure (CVP) and inotrope/vasopressor therapy.

Results

Sixty-three consecutive patients with AP were initially evaluated. Inter-hospital transfers with established organ dysfunction (n = 11) or where records had insufficient detail (n = 22) were excluded. In the remaining 30 patients, in-hospital death occurred in 7. The cumulative volume of crystalloid given was significantly less at 48 h in patients who died in hospital (3331 ± 800 ml vs. survivors, 7287 ± 544 ml; P < 0.001). Non-survivors had a higher CVP, and received more inotropes/vasopressors.

Conclusion

In severe AP-associated organ failure, fluid resuscitation profiles differ between survivors and non-survivors. CVP alone as a crude indicator of adequate resuscitation may be unreliable, potentially leading to the use of inotropes/vasopressors in the inadequately filled patient.     

Pancreatic cancer causing acute pancreatitis: a comparative study with cancer patients without pancreatitis and pancreatitis patients without cancer

Background/purpose

Although pancreatic cancer produces upstream obstructive pancreatitis, acute pancreatitis is a less common manifestation of pancreatic cancer. This study aimed to clarify the subgroup of pancreatic cancer patients who present with an episode of acute pancreatitis (Group I) in comparison with a matched group of pancreatic cancer patients without pancreatitis (Group II) and another group of acute pancreatitis patients without pancreatic cancer (Group III).

Methods

This was a retrospective comparative study of 18 patients in Group I, 300 patients in Group II and 141 patients in Group III.

Results

The mean age of Group I was 63.7 years and the male to female ration was 1:0.3. Serum CA 19-9 levels were elevated in 80 %. The main pancreatic duct was incompletely obstructed in 7 patients. There were no significant differences in location of tumor, clinical stage, resection rate and survival months between Group I and II. Acute pancreatitis secondary to pancreatic cancer was more likely to be mild (94 vs. 72 %, p < 0.05) and relapsed (39 vs. 16 %, p < 0.05) compared with Group III.

Conclusions

Anatomic evaluation of the pancreas should be performed in patients with acute pancreatitis with no obvious etiology, even if the pancreatitis is mild, to search for underlying malignancy.     

Acute pancreatitis associated with intra-aortic balloon pump placement

An 85-year-old white woman underwent placement of an intra-aortic balloon pump for stabilization prior to planned bypass surgery. The complication of acute pancreatitis was attributed to atheroemboli or compromise of circulation to the pancreas. Ischemia as a possible etiology of pancreatitis is discussed. © 1996 Wiley-Liss, Inc.     

Emergence of multidrug resistant infection in patients with severe acute pancreatitis

Background/objectivesInfection is the most important risk factor contributing to death in severe acute pancreatitis. Multidrug resistant (MDR) bacterial infections are an emerging problem in severe acute pancreatitis.MethodsFrom January 2009 to December 2011 the medical records of 46 patients with infected severe acute pancreatitis were reviewed retrospectively to identify risk factors for the development of MDR bacterial infection and assess the related outcomes.ResultsThe mean age of the 46 patients was 55 years; 38 were males. Thirty-six patients (78.3%) had necrotizing pancreatitis and all of enrolled 46 patients had suspected or proven pancreatic infection. MDR microorganisms was found in 29 (63%) of the 46 patients. A total of 51 episodes of MDR infection were collected from 11 cases of infected pancreatic pseudocysts, 36 cases of infected necrosis/infected walled-off necrosis and 4 cases of bacteremia. The most frequent MDR bacteria was methicillin-resistant Staphylococcus aureus (n = 15). Transferred patients had a higher incidence of MDR infections than primarily admitted patients (72% vs. 35%, P = .015). The mean intensive care unit stay was significantly longer in patients with MDR bacterial infections (20 vs. 2 days, P = .001). Mortality was not significantly different in the patients with MDR infections vs. those without it (14% vs. 6%, P = .411).ConclusionsClinicians should be aware of the high incidence of MDR bacterial infections in patients with severe acute pancreatitis, especially referred patients. Empiric therapy directed at these pathogens may be used in patients where severe sepsis persists, until definitive culture results are obtained.     

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.     

胆宁片联合奥曲肽治疗急性胰腺炎的临床效果观察

[目的]观察胆宁片联合奥曲肽治疗急性胰腺炎的临床效果。[方法]将28例急性胰腺炎患者随机分为治疗组与对照组,各14例。治疗组以胆宁片联合奥曲肽治疗;对照组单用奥曲肽治疗。观察2组患者治疗后腹痛腹胀缓解时间、肠道功能恢复时间、白细胞计数变化、血淀粉酶、C反应蛋白(CRP)变化,并发症及住院天数等指标。[结果]治疗组在腹痛腹胀缓解时间、肠道功能恢复时间、血CRP、并发症控制等方面均优于对照组(P0.05),但2组血淀粉酶降低程度比较,差异无统计学意义(P0.05)。[结论]胆宁片联合奥曲肽在治疗急性胰腺炎有协同作用,可提高疗效,缩短住院时间。     

急性胰腺炎CT检查时机选择

目的探讨急性胰腺炎患者最佳CT检查时间。方法本研究选择2008年1月~2010年3月对确诊的172例急性胰腺炎的患者,随机分为3组,分别在发病≤12 h、12~24 h、48~72 h行CT检查。为观察病情变化,在发病≤12 h行CT检查的患者在72~120 h期间行第二次CT检查,分析不同时间段的CT检出率和Balthazar分级情况,以确定最佳CT检查时间。结果随着时间的推移,CT检查发现胰腺炎的阳性率逐渐增高,88.7%的患者12~24 h CT检查阳性率明显高于在发病12 h之内行CT检查的阳性率,差异显著（P〈0.05）,但与在发病48~72 h和72~120 h行CT相比,无显著差异（P〉0.05）。按照Balthazar CT分级标准,对确诊的胰腺炎患者不同时间段分级进行研究发现：随着时间的延长,患者D级、E级检出率逐渐增多,48~72 h D级、E级检出率明显高于12 h之内和12~24 h之间检出率（P〈0.05）;但与72~120 h相比,无显著性差异（P〉0.05）。结论对于疑诊胰腺炎的患者在发病12~24 h行CT检查可较早检测到胰腺炎的变化;在48~72 h行CT检查可较早检测到胰腺炎的严重程度。     

Trefoil factor-2, an early predictor for acute gastrointestinal injury in patients with acute pancreatitis

Acute gastrointestinal injury (AGI) is commonly present in patients with acute pancreatitis (AP). It is often difficult to predict gastrointestinal function in the early stage due to lack of reliable markers. We aimed to assess whether early plasma trefoil factor 2 (TFF-2) is a potential predictor for AGI.Fifty one patients were included for the onset of AP (from developing abdominal pain) within 72 hours in this prospective observational single-center study from January 2013 to July 2015. Among them 23 patients were classified as mild, 17 as moderately severe, and 11 as severe according to 2012 Atlanta classification. Plasma samples were collected only once at admission to the ICU. Twenty samples of healthy adults were also collected as control. The TFF-2 levels were determined by using a human TFF-2 enzyme-linked immunoassay. AGI grades from 1st to 7th day after admission were observed.The plasma TFF-2 levels among AP patients in early stage were significantly higher than healthy controls (766.41 ng/mL vs 94.37 ng/mL, P < .0001). The correlations between TFF-2 levels and AGI grades from 1st to 4th day after admission were positive (r = 0.47, 0.43, 0.42, 0.40 respectively, P < .05). As a predictor of acute gastrointestinal failure, plasma TFF-2 was superior to others: Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, procalcitonin, C-reactive protein, serum calcium. In addition, TFF-2 increased along with the severity of AP (r = 0.554, P < .0001) and associated with Acute Physiology and Chronic Health Evaluation II, sequential organ failure assessment, C-reactive protein, serum calcium.The plasma TFF-2 levels were increased in patients in early stage of AP and correlated with AGI grades and disease severity in our study. TFF-2 might be a potential predictor for acute gastrointestinal failure in patients with AP.