Insufficient etiological workup of COVID-19-associated acute pancreatitis: A systematic review

BACKGROUND Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection, mostly causing respiratory symptoms, is also known to affect the gastrointestinal tract. Several case reports hypothesize that SARS-CoV-2 could be an etiological factor in acute pancreatitis(AP).AIM To assess all the available evidence in the literature relating to coronavirus disease 2019(COVID-19) and AP.METHODS We performed a systematic review of the available literature on the topic. The systematic search was conducted on 15 May 2020 on MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus with a search key using the terms "amylase," "lipase," "pancr*," "COVID-19" and synonyms. Due to the low quality and poor comparability of the studies, a meta-analysis was not performed.RESULTS Six case reports and two retrospective cohorts were included, containing data on eleven COVID-19 patients with AP. Five patients had AP according to the Atlanta classification. Other publications did not provide sufficient information on the diagnostic criteria. Most cases were considered SARS-CoV-2-induced, while several established etiological factors were not investigated. We were able to identify other possible causes in most of them.CONCLUSION We strongly highlight the need for adherence to the guidelines during a diagnostic and etiological workup, which could alter therapy.     

肿瘤坏死因子α及淀粉酶对重症急性胰腺炎外科重症监护的临床干预及其效果评价

目的评价肿瘤坏死因子α（TNF-α）以及血、尿淀粉酶在外科ICU对重症急性胰腺炎患者临床干预的效果。方法回顾性分析我院外科ICU收治的32例急性重症胰腺炎患者,经我院外科ICU监护及治疗,比较治疗前后各组的TNF-α以及淀粉酶的结果。结果32例患者在临床干预后,TNF-α的曲线下面积为0．94,灵敏度为97％,特异度为90％;血淀粉酶的曲线下面积为0．89,灵敏度为93％,特异度为85％;尿淀粉酶的曲线下面积为0．87,灵敏度为75％,特异度为96％。结论TNF—α比淀粉酶能更好地用于评价急性重症胰腺炎患者的临床干预效果。     

High-calorie, rice-derived, short-chain, glucose polymer-based oral rehydration solution in acute watery diarrhea

In this study, we have compared the effects of the World Health Organization oral rehydration solution (WHO ORS) and an ORS containing short polymers of glucose (Amylyte ORS) at a high caloric density (five times) and comparable osmolality, on stool output, duration of diarrhea, weight gain and fluid and electrolyte balance, in randomized, open-labeled, controlled clinical trials in five centers. A total of 198 male children (4 months to 10 years) with acute diarrhea (<72 h after onset) were assigned by random allocation to either WHO ORS or Amylyte ORS at five centers in Asia. Children were stratified according to grade of dehydration (mild, moderate or severe) and the initial purging rates during the first 6h (low (<2ml/kg/h), moderate (2–5ml/kg/h) and high (>5ml/kg/h) purgers). The clinical characteristics of the children in the two treatment groups were comparable. Amylyte ORS reduced stool volumes significantly in children with severe dehydration (285.4 ± 74.2 versus 75.5 ±20.0 ml/kg; p < 0.05) and in children with a high initial purging rate (200.3 ±42.8 versus 130.5 ± 9.1 ml/kg; p < 0.05). This was accompanied by a significant (276.4 ±14.6 versus 227.6 ± 11.8 ml/kg; p < 0.01) reduction in ORS requirements in the Amylyte ORS treated group, the effect being greatest in children with severe dehydration (491.5 ± 108.5 versus 155.7 ± 27.3 ml/kg; p < 0.01) or high initial purging rates (394.2 ± 66.2 versus 316.8 ± 34.8 ml/kg; p < 0.05). In mild or moderate dehydration and low or moderate purgers, duration of diarrhea in children treated with Amylyte ORS was not reduced. A significant (p < 0.05) reduction in duration of diarrhea was found in children with severe dehydration (56.4 ± 1.8 versus 34.0 ± 5.6h) or high purging rates (51.5 ± 7.1 versus 38.2 ± 4.8 h). Significantly (p < 0.0001) greater weight gain (520.3 ± 48.5 g versus 228.5 ± 42.1 g) and percent gain in weight (4.8 ± 0.4% versus 2.3 ± 0.4%) were found in children given Amylyte ORS compared with those given WHO ORS. Amylyte ORS rehydrated children with acute diarrhea, reduced stool volume, duration of diarrhea and ORS requirements in children with severe dehydration or high initial purging rates, and improved weight gain. Amylyte ORS has the advantage of containing short polymers of glucose that provide over five times the calories per liter than the glucose-based WHO ORS.     

In vivo and in vitro antidiabetic effect of Cistus laurifolius L. and detection of major phenolic compounds by UPLC–TOF-MS analysis

Ethnopharmacological relevance

In Turkish folk medicine, various parts of Cistus laurifolius L. are used to treat gastric ulcer and various types of pains. Additionally the tea prepared from the leaves is used to decrease symptoms of diabetes.

Materials and methods

In the present study, the hypoglycemic effects of aqueous and ethanol extracts of Cistus laurifolius were investigated in normal, glucose loaded hyperglycemic and streptozocin (STZ)-induced diabetic rats. α-Glucosidase and α-amylase enzyme inhibitory effects were determined to evaluate the mechanism of action. Total phenolic content of the extracts were determined by using Folin–Ciocalteu reagent and Ultra Performance Liquid Chromatography–Time of Flight Mass Spectrometer (UPLC–TOF-MS) was used to detect the major phenolic compounds in the extract.

Results

Results indicated that blood glucose levels of the STZ-induced diabetic rats were decreased by ethanol extract at of 250 and 500 mg/kg doses as compared to control group (16%–34%). In glucose loaded animals, extracts have shown a weak hypoglycemic effect (11%–20%). Additionally, the ethanol extract of Cistus laurifolius is found to be a potent inhibitor of α-glucosidase and α-amylase, possibly due to several polyphenolic compounds present within the extract. Twelve major flavonoids (apigenin, quercetin, kaempferol, naringenin, quercitrin and their derivatives), gallic, ellagic and chlorogenic acid in chromatographic fingerprint were analyzed by the on-line UPLC–TOF-MS system.

Conclusions

Due to having inhibitory effect on blood glucose level and carbohydrate digesting enzymes (α-glucosidase and α-amylase), Cistus laurifolius leaves might be beneficial for diabetic patients.     

柴芩承气汤对急性重症胰腺炎的疗效观察及部分机制

目的:探究柴芩承气汤加减联合西医治疗急性重症胰腺炎的临床效果,并对其作用机制进行研究,以期丰富治疗方法,降低急性重症胰腺炎并发症,提高疗效。方法:选取2017年1月至2018年2月绵阳市中心医院收治的急性重症胰腺炎患者62例作为研究对象,按照就诊顺序编号,采用数字随机表法分为对照组和观察组,每组31例。对照组给予心电监护、禁食禁饮、胃肠减压、抑酸、维持内环境稳定、抗菌、抑制胰腺分泌和胰腺活性、止痛等治疗,观察组在对照组基础上加用柴芩承气汤加减治疗,且经胃管给药,均同时治疗2周。观察2组治疗前、治疗后血清淀粉酶、脂肪酶变化并比较;观察治疗前、治疗后在白细胞(WBC)、超敏C反应蛋白(hs-CRP)、内毒素、白细胞介素-6(IL-6)变化并比较;观察治疗前、治疗后在免疫功能指标CD4~+、CD8~+、CD4~+/CD8~+情况并比较;治疗过程中进行不良反应观察并比较;治疗后进行疗效比较。结果:1)2组患者治疗前血淀粉酶、尿淀粉酶、脂肪酶比较,差异无统计学意义(P0.05),治疗后2组以上指标较治疗前显著下降,差异有统计学意义(P0.05),治疗后观察组患者以上指标显著低于对照组,差异有统计学意义(P0.05);2)2组患者治疗前WBC、CRP、内毒素、IL-6指标比较,差异无统计学意义(P0.05),治疗后以上指标2组较治疗前均显著下降,差异有统计学意义(P0.05),治疗后观察组患者以上指标显著低于对照组,差异有统计学意义(P0.05)。3)2组患者治疗前CD4~+、CD8~+、CD4~+/CD8~+比较,差异无统计学意义(P0.05),治疗后CD4~+、CD8~+、CD4~+/CD8~+2组较治疗前显著升高,CD8~+则显著下降,差异有统计学意义(P0.05),治疗后观察组患者以上指标显著优于对照组,差异有统计学意义(P0.05)。4)完成治疗后观察组患者治愈率、总有效率明显高于对照组,差异有统计学意义(P0.05)。5)2组恶心呕吐、腹痛腹泻、头晕不良反应发生率比较,差异无统计学意义(P0.05)。结论:柴芩承气汤能抑制急性重症胰腺炎血清淀粉酶和脂肪酶,抑制炎性反应,改善免疫力,提高疗效。     

Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis

BackgroundThe development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes.MethodsFifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters.ResultsInfected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient.ConclusionAmylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome.     

肾综合征出血热患者胰腺功能变化的临床研究

将６５例确诊为肾综合征出血热（ＨＦＲＳ）的住院患者列为观察组,选１０例正常者为对照组,监测ＨＦＲＳ患者各期的空腹血糖、血淀粉酶,脂肪酶及胰岛素含量并随机选出３０例ＨＦＲＳ患者,于发热末期或少尿期行口服葡萄糖耐量试验及胰岛素释放试验（口服７５ｇ糖）。发现ＨＦＲＳ患者在发热期即出现血糖、血淀粉酶,脂肪酶及胰岛素水平升高,服糖后胰岛素释放减少,糖耐量减低。此变化在少尿期最显著,多尿期次灾,恢复期渐正常,     

The Clinical Significance of Salivary Amylase in Duodenal Aspirates in Evaluation of Exocrine Pancreas Function

Salivary and pancreatic amylases in duodenal aspirates were quantitated in 419 consecutive tests performed on 378 patients suspected of having insufficiency of the exocrine pancreatic function. Salivary amylase was detected in samples from 31% of the tests. However, the amount of salivary amylase was sufficient to cause a misinterpretation in 13 tests only. Five of these tests originated from patients with a history of surgery for peptic ulcer disease. This group of patients tended to have large amounts of salivary amylase in the duodenal aspirates. In the unoperated patients (n = 336) 200 tests yielded values for the total amylase concentration above the lower level of the reference interval, and only in 8 of these tests (4%) did correction for salivary amylase change the results to values below the reference interval. It it concluded that quantitation of isoamylase activity in duodenal samples is unlikely to be of significant value in patients without a history of surgery for peptic ulcer disease.     

What should we trust to define,predict and assess pancreatic fistula after pancreatectomy?

ObjectiveThe ISGPF postoperative pancreatic fistula (POPF) definition using amylase drain concentration is widely used. However, the interest of lipase drain concentration, daily drain output and absolute enzyme daily production (concentration x daily drain volume) have been poorly investigated.Material and methodsThese predictive on postoperative day (POD) 1, 3, 5 and 7 were analyzed in a development cohort, and subsequently tested in an independent validation cohort.ResultsOf the 227 patients of the development cohort, 17% developed a biochemical fistula and 34% a POPF (Grade B/C). Strong correlation was found between amylase/lipase drain concentration at all postoperative days (ρ = 0.90; p = 0.001). Amylase and lipase were both significantly higher in patients with a POPF (p < 0.001) presenting an equivalent under the ROC curve area (0.85 vs 0.84; p = 0.466). Combining POD1 and POD3 threefold enzyme cut-off value increased significantly POPF prediction sensibility (97.4% vs 77.8%) and NPV (97.1% vs 86.3%). These results were also confirmed in the validation cohort of 554 patients. Finally, absolute enzyme daily production and daily drain output were significantly higher in patients with a POPF (p < 0.001) but did not add clinical value when compared to drain enzyme concentration.ConclusionLipase is as effective as amylase drain concentration to define POPF. Absolute enzyme daily production or daily drain output do not help to better predict clinically significant POPF occurrence and severity. Lipase and amylase should mainly be used for their negative predictive value to predict the absence of clinically significant POPF and could allow early drain removal and hospital discharge.     

Time-course of changes in pancreatic size and enzyme composition in rats during starvation

The effect of starvation for 3, 5, or 7 d on body weight, fat stores, pancreatic weight, and enzyme composition was studied in 300 g rats and was compared with a. 3-d fast in 200 g rats. In the 300 g animals, fasting led to a gradual hypotrophy of the pancreas with a marked, continuous decrease in amylase content. Pancreatic lipase, trypsinogen, chymotrypsinogen, proelastase, and secretory trypsin inhibitor contents increased temporarily, but by d 7, they declined to about the initial values. This decline in enzyme levels coincided with the exhaustion of fat stores. The decrease in amylase content could be related to decreases in circulating insulin levels, whereas the temporary increase in lipase content may be owing to changes in plasma free fatty acid concentrations. In 200 g rats, starvation for 3 d led to exhaustion of fat stores that was accompanied by greater losses of pancreatic weight, protein, and amylase contents. In addition, the levels of trypsinogen and chymotrypsinogen decreased and lipase was unchanged. These findings indicate that during starvation, changes in pancreatic secretory enzymes are time-dependent and vary with the age, body weight, and/or adipose tissue mass of the rats.