Pancreatic Duct Patterns in Acute Pancreatitis: A MRI Study

Objectives

To study the MRI findings of the pancreatic duct in patients with acute pancreatitis.

Materials and Methods

A total of 239 patients with acute pancreatitis and 125 controls were analyzed in this study. The severity of acute pancreatitis was graded using the MR severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II(APACHE II) scoring systems. The number of main pancreatic duct (MPD) segments visualized, and both MPD diameter and pancreatic duct disruption were noted and compared with the severity of acute pancreatitis.

Results

The frequency of MPD segment visualization in the control group was higher than that in the acute pancreatitis group (p<0.05). The number of MPD segments visualized was negatively correlated with the MRSI score (p<0.05) and the APACHE II score (p<0.05). There was no difference in the MPD diameter between the acute pancreatitis and control groups or among the patients with different severities of acute pancreatitis (p>0.05). The prevalence of pancreatic duct disruption was 7.9% in the acute pancreatitis group. The prevalences of pancreatic duct disruption were 4.8% and 15.3% in the mild and severe acute pancreatitis groups based on the APACHE II score, respectively, and were 0%, 5.7% and 43.5% in the mild, moderate and severe acute pancreatitis groups according the MRSI score, respectively. The prevalence of pancreatic duct disruption was correlated with the severity of acute pancreatitis based on the APACHE II score (p<0.05) and MRSI score (p<0.05).

Conclusion

The pancreatic duct in acute pancreatitis patients was of normal diameter. The number of MPD segments visualized and visible pancreatic duct disruption on MRI may be supplementary indicators for determining the severity of acute pancreatitis.     

Factors Affecting Outcome in Acute Hypertriglyceridemic Pancreatitis Treated with Plasma Exchange: An Observational Cohort Study

Objectives

The optimal therapy for hypertriglyceridemic acute pancreatitis, especially the role of plasma exchange (PE), is not entirely clear. The aim of our large, single-center, observational, cohort study was to analyze the factors affecting outcome in hypertriglyceridemic pancreatitis treated with PE.

Methods

We included 111 episodes of hypertriglyceridemic pancreatitis treated with PE, which occurred in 103 different patients. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, triglycerides, delay to first PE, and PE treatment details were retrospectively obtained from the patients’ records. The main outcome measures were length of hospitalization and in-hospital mortality.

Results

The patients were 47±9 years old and the median APACHE II score at first PE was 4 (inter-quartile range (IQR) 2–7). There was a seasonal variation in the incidence of hypertriglyceridemic pancreatitis, and the recurrence rate was 1.6% per year. Triglycerides at presentation did not correlate with APACHE II or influence the outcome. The mean reduction in triglycerides during PE was 59% (from 44±31 to 18±15 mmol/l), which was twice the reduction observed during conservative treatment (27% daily). The median hospital stay was 16 days (IQR 10–24) and in-hospital mortality was 5%. The median delay to first PE was 35 hours (IQR 24–52), and there was no difference in mortality in the early and late PE groups (7% vs. 6%, p = 0.79). The group with citrate anticoagulation during PE had a significantly lower mortality than the group with heparin anticoagulation (1% vs. 11%, p = 0.04), and citrate was an independent predictor also in the multivariate model (p = 0.049).

Conclusions

PE effectively reduced serum triglycerides faster than could be expected with conservative treatment. The delay in PE therapy did not influence survival. We found that citrate anticoagulation during PE was associated with reduced mortality, which should be confirmed in a randomized study.     

Procalcitonin Levels Predict Acute Kidney Injury and Prognosis in Acute Pancreatitis: A Prospective Study

Background

Acute kidney injury (AKI) has been proposed as a leading cause of mortality for acute pancreatitis (AP) patients admitted to the intensive care unit (ICU). This study investigated the predictive value of procalcitonin (PCT) for AKI development and relevant prognosis in patients with AP, and compared PCT’s predictive power with that of other inflammation-related variables.

Methods

Between January 2011 and March 2013, we enrolled 305 cases with acute pancreatitis admitted to ICU. Serum levels of PCT, serum amyloid A (SAA), interleukin-6 (IL-6), and C reactive protein (CRP) were determined on admission. Serum PCT was tested in patients who developed AKI on the day of AKI occurrence and on either day 28 after occurrence (for survivors) or on the day of death (for those who died within 28 days).

Results

Serum PCT levels were 100-fold higher in the AKI group than in the non-AKI group on the day of ICU admission (p<0.05). The area under the receiver-operating characteristic (ROC) curve of PCT for predicting AKI was 0.986, which was superior to SAA, CRP, and IL-6 (p<0.05). ROC analysis revealed all variables tested had lower predictive performance for AKI prognosis. The average serum PCT level on day 28 (2.67 (0.89, 7.99) ng/ml) was significantly (p<0.0001) lower than on the day of AKI occurrence (43.71 (19.24,65.69) ng/ml) in survivors, but the serum PCT level on death (63.73 (34.22,94.30) ng/ml) was higher than on the day of AKI occurrence (37.55 (18.70,74.12) ng/ml) in non-survivors, although there was no significant difference between the two days in the latter group (p = 0.1365).

Conclusion

Serum PCT is superior to CRP, IL-6, and SAA for predicting the development of AKI in patients with AP, and also can be used for dynamic evaluation of AKI prognosis.     

肠功能障碍评分对于急性胰腺炎预后判断的价值

目的:目前判断急性胰腺炎预后的预测方法的准确度尚不能满足临床需要.本研究通过将5级肠功能衰竭(GIF)评分系统与SOFA评分系统结合,探讨GIF评分系统在急性胰腺炎预后中的价值.方法:回顾性分析2008年9月～2012年4月在西京消化病医院重症监护室住院的241例急性胰腺炎病例资料.计算患者入院后前3天的SOFA及GIF评分.应用受试者工作曲线下面积(AUC)比较GIF评分、SOFA评分及SOFA联合GIF评分(联合评分)对急性胰腺炎预后的判断价值.结果:235例患者纳入最终分析.死亡率随着入院后前3天GIF评分均值的升高而增加.联合评分有最大的AUC(0.849),显著高于单独使用SOFA评分(0.793,P=0.002),GIF评分的AUC是0.812.入院后前3天内发生肠功能衰竭和未发生肠功能衰竭的患者入院后30天内的的死亡率分别是45.5％和5.2％ (log-rank test=60.306;P=0.000).结论:GIF评分可用于对急性胰腺炎预后的评估,GIF评分与SOFA评分联合应用对预后判断的准确度高于单独运用其中任一个.     

Retrocrural Space Involvement on Computed Tomography as a Predictor of Mortality and Disease Severity in Acute Pancreatitis

Background

Because computed tomography (CT) has advantages for visualizing the manifestation of necrosis and local complications, a series of scoring systems based on CT manifestations have been developed for assessing the clinical outcomes of acute pancreatitis (AP), including the CT severity index (CTSI), modified CTSI, etc. Despite the internationally accepted CTSI having been successfully used to predict the overall mortality and disease severity of AP, recent literature has revealed the limitations of the CTSI. Using the Delphi method, we establish a new scoring system based on retrocrural space involvement (RCSI), and compared its effectiveness at evaluating the mortality and severity of AP with that of the CTSI.

Methods

We reviewed CT images of 257 patients with AP taken within 3–5 days of admission in 2012. The RCSI scoring system, which includes assessment of infectious conditions involving the retrocrural space and the adjacent pleural cavity, was established using the Delphi method. Two radiologists independently assessed the RCSI and CTSI scores. The predictive points of the RCSI and CTSI scoring systems in evaluating the mortality and severity of AP were estimated using receiver operating characteristic (ROC) curves.

Principal Findings

The RCSI score can accurately predict the mortality and disease severity. The area under the ROC curve for the RCSI versus CTSI score was 0.962±0.011 versus 0.900±0.021 for predicting the mortality, and 0.888±0.025 versus 0.904±0.020 for predicting the severity of AP. Applying ROC analysis to our data showed that a RCSI score of 4 was the best cutoff value, above which mortality could be identified.

Conclusion

The Delphi method was innovatively adopted to establish a scoring system to predict the clinical outcome of AP. The RCSI scoring system can predict the mortality of AP better than the CTSI system, and the severity of AP equally as well.     

Expression and Clinical Significance of CK19 and CK20 Expressions in Transverse Mesocolon Biopsies from Patients with Gastric Carcinoma

We sought to evaluate in this study the significance of cytokeratin (CK)-19 and CK-20 in determining the peritoneal micrometastasis of gastric carcinoma and also determine the factors related with the occurrence of peritoneal micrometastasis. For this purpose, 152 patients with gastric cancer were enrolled in the study and transverse mesocolon biopsies were undertaken intraoperatively. The CK19 and CK20 immunohistochemical staining were performed on the tissue samples, and the results were compared with those of H&E staining and peritoneal lavage cytology (PLC). Our data show that the positivity rates of CK19 and CK20 in transverse mesocolon were 48.6 and 61.2%, respectively, which were significantly higher (P < 0.05) than that (10.0%) of PLC. Besides, the positivity rate increased with the depth of tumor invasion. Based on these data, we concluded that CK19 and CK20 expressions could be adopted to determine the peritoneal micrometastasis for accurate clinical staging of the patients. These data provide reliable guideline for postoperative treatment and prognosis of gastric carcinoma.     

Phospholipid Transverse Diffusion in Synaptosomes: Evidence for the Involvement of the Aminophospholipid Translocase

We have studied in Torpedo marmorata electric organ synaptosomes the equilibration kinetics of spin-labeled phospholipid analogues initially incorporated into the outer plasma membrane monolayer. As assayed by evoked releases of both ATP and acetylcholine, the nerve endings were closed vesicles containing an energy source. The aminophospholipids (phosphatidylethanolamine and phosphatidylserine) were translocated toward the inner membrane leaflet faster and to a higher extent than their choline-containing counterparts (phosphatidylcholine and sphingomyelin). This difference was abolished by incubation of synaptosomal membranes with N-ethylmaleimide, suggesting that the accumulation of aminophospholipids in the inner layer was driven by a protein. This phenomenon is comparable with what was described in plasma membranes of other eucaryotic cells (erythrocyte, lymphocyte, platelet, fibroblast), and thus we would suggest that an aminophospholipid translocase, capable of moving the aminophospholipids from the outer to the inner layer at the expense of ATP, is also present in the synaptosomal plasma membrane.     

Increased Risk of Acute Pancreatitis in Patients with Type 2 Diabetes: An Observational Study Using a Japanese Hospital Database

Background

Increased risks of acute pancreatitis in patients with type 2 diabetes mellitus have been reported recently in several countries. We aimed to estimate the risks of acute pancreatitis in Japanese patients with diabetes mellitus.

Methods/Findings

We examined a large-scale hospital administrative database consisting of one million patients in 16 secondary medical care hospitals, from 2003 to 2010. The incidence rates of acute pancreatitis were estimated with cohort design; the odds ratios associated with diabetes mellitus and other comorbid risk factors were estimated with separate case-control analyses.In cohort analysis, the incidence of acute pancreatitis was higher in 14,707 diabetic patients than in 186,032 non-diabetic patients (4.75 vs. 1.65 per 1,000 patient-years) and increased in male patients and as age advanced. The adjusted odds ratio of acute pancreatitis in patients with diabetes mellitus was 1.86 (P<0.001) compared with non-diabetic patients in case-control analysis from 1,372 cases and 5,469 matched controls, which is consistent with the ones reported in previous studies. Alcoholism and gallstones were associated with a large increase in the risk of acute pancreatitis (adjusted odds ratio 13.40 and 14.29, respectively, P<0.001), although dyslipidemia was associated with significant risk reduction (adjusted odds ratio 0.62, P<0.001).

Conclusions

This observational study ascertained the elevated incidence rates and risk of acute pancreatitis in Japanese patients with diabetes. The risk estimates in Japanese patients with diabetes were in agreement with the ones reported in previous studies, and the elevated risk of acute pancreatitis in patients with diabetes would be generalized in different locations/populations.     

Impact of Global Fxr Deficiency on Experimental Acute Pancreatitis and Genetic Variation in the FXR Locus in Human Acute Pancreatitis

Background

Infectious complications often occur in acute pancreatitis, related to impaired intestinal barrier function, with prolonged disease course and even mortality as a result. The bile salt nuclear receptor farnesoid X receptor (FXR), which is expressed in the ileum, liver and other organs including the pancreas, exhibits anti-inflammatory effects by inhibiting NF-κB activation and is implicated in maintaining intestinal barrier integrity and preventing bacterial overgrowth and translocation. Here we explore, with the aid of complementary animal and human experiments, the potential role of FXR in acute pancreatitis.

Methods

Experimental acute pancreatitis was induced using the CCK-analogue cerulein in wild-type and Fxr^-/- mice. Severity of acute pancreatitis was assessed using histology and a semi-quantitative scoring system. Ileal permeability was analyzed in vitro by Ussing chambers and an in vivo permeability assay. Gene expression of Fxr and Fxr target genes was studied by quantitative RT-PCR. Serum FGF19 levels were determined by ELISA in acute pancreatitis patients and healthy volunteers. A genetic association study in 387 acute pancreatitis patients and 853 controls was performed using 9 tagging single nucleotide polymorphisms (SNPs) covering the complete FXR gene and two additional functional SNPs.

Results

In wild-type mice with acute pancreatitis, ileal transepithelial resistance was reduced and ileal mRNA expression of Fxr target genes Fgf15, SHP, and IBABP was decreased. Nevertheless, Fxr^-/- mice did not exhibit a more severe acute pancreatitis than wild-type mice. In patients with acute pancreatitis, FGF19 levels were lower than in controls. However, there were no associations of FXR SNPs or haplotypes with susceptibility to acute pancreatitis, or its course, outcome or etiology.

Conclusion

We found no evidence for a major role of FXR in acute human or murine pancreatitis. The observed altered Fxr activity during the course of disease may be a secondary phenomenon.     

Cell Death and DAMPs in Acute Pancreatitis

Cell death and inflammation are key pathologic responses of acute pancreatitis (AP), the leading cause of hospital admissions for gastrointestinal disorders. It is becoming increasingly clear that damage-associated molecular pattern molecules (DAMPs) play an important role in the pathogenesis of AP by linking local tissue damage to systemic inflammation syndrome. Endogenous DAMPs released from dead, dying or injured cells initiate and extend sterile inflammation via specific pattern recognition receptors. Inhibition of the release and activity of DAMPs (for example, high mobility group box 1, DNA, histones and adenosine triphosphate) provides significant protection against experimental AP. Moreover, increased serum levels of DAMPs in patients with AP correlate with disease severity. These findings provide novel insight into the mechanism, diagnosis and management of AP. DAMPs might be an attractive therapeutic target in AP.     

自噬在胰腺炎中的研究及进展

自噬是广泛存在于真核细胞内的一种溶酶体依赖性降解途径,作为细胞生存的一种机制,在很多生理过程如清除损伤、衰老细胞器以及冗余蛋白上发挥重要作用。自噬在人类胰腺炎的研究最早由Helin等人早在1980年提出,随着不断深入研究,发现自噬在胰腺炎发生发展过程中起主导作用。急性胰腺炎是一种发病率和死亡率极高的疾病,目前表明这种疾病始于胰腺腺泡细胞,主要诊断指标为高淀粉酶血症,胰腺腺泡细胞内消化酶的激活、液泡的大量堆积和炎症因子的聚集,最终胰腺炎症细胞侵润及引起的全身炎症反应导致腺泡细胞的凋亡和坏死,在其发病机制和治疗方面仍需进一步研究探讨。本文综述近年最新研究成果,深入探讨自噬在胰腺炎中的研究及进展。     

Increased Risk of Acute Pancreatitis in Patients with Rheumatoid Arthritis: A Population-Based Cohort Study

The study was conducted to determine whether patients with rheumatoid arthritis (RA) are at increased risk of acute pancreatitis compared with those without RA and to determine if the risk of acute pancreatitis varied by anti-RA drug use. We used the large population-based dataset from the National Health Insurance (NHI) program in Taiwan to conduct a retrospective cohort study. Patients newly diagnosed with RA between 2000 and 2011 were referred to as the RA group. The comparator non-RA group was matched with propensity score, using age and sex, in the same time period. We presented the incidence density by 100,000 person-years. The propensity score and all variables were analyzed in fully adjusted Cox proportional hazard regression. The cumulative incidence of acute pancreatitis was assessed by Kaplan-Meier analysis, with significance based on the log-rank test. From claims data of one million enrollees randomly sampled from the Taiwan NHI database, 29,755 adults with RA were identified and 119,020 non- RA persons were matched as a comparison group. The RA cohort had higher incidence density of acute pancreatitis (185.7 versus 119.0 per 100,000 person-years) than the non-RA cohort. The adjusted hazard ratio (HR) was 1.62 (95% CI [confidence interval] 1.43–1.83) for patients with RA to develop acute pancreatitis. Oral corticosteroid use decreased the risk of acute pancreatitis (adjusted HR 0.83, 95% CI 0.73–0.94) but without a dose-dependent effect. Current use of disease modifying anti-rheumatic drugs or tumor necrosis factor blockers did not decrease the risk of acute pancreatitis. In conclusion, patients with RA are at an elevated risk of acute pancreatitis. Use of oral corticosteroids may reduce the risk of acute pancreatitis.     

ERCP治疗急性胆源性胰腺炎

急性胆源性胰腺炎(ABP)是消化内科常见急腹症之一,是急性胰腺炎中最常见的类型,占急性胰腺炎每年发病人数的40%-60%,病死率较高,常规药物治疗不能从根本上解除病因,易导致复发,手术治疗风险较大,创伤较大,费用较高,住院时间较长,易引起其术后并发症,不利于患者恢复。而经内镜逆行胰胆管造影(ERCP)作为一种内镜与放射技术相结合的诊断治疗方法,对胆管内结石并发急性胰腺炎的诊断率是最高的,诊断结石的敏感性大于95%。在20世纪70年代被认为是急性胆源性胰腺炎的禁忌症,近年来随着ERCP技术的不断发展和广泛应用,ERCP已成为治疗胆胰疾病的一种安全有效的技术。ERCP可清除胆管结石,从而达到通畅胆道,减少胆汁向胰管反流,迅速改善患者病情,阻断病情进展的目的,并有效缩短住院时间,减轻患者痛苦,减少复发和改善总体预后,为广大ABP患者带来了福音,此外,还能减少患者住院费用,节省医疗资源,对于个人及社会均具有积极意义,值得推广。     

连续性血液净化在重症急性胰腺炎患者中应用的临床疗效观察

目的:观察连续性血液净化(CBP)在重症急性胰腺炎(SAP)患者中应用的临床疗效,探讨提高SAP临床疗效的治疗措施方法:选择在我科就诊的SAP患者64例,根据患者自愿的原则,分为常规组和CBP组,常规组采用内科常规治疗措施,CBP组在常规治疗的基础上加行CBP治疗,比较两组患者治疗中血清淀粉酶的动态改变、治疗第5天各项生化指标及APACHEⅡ评分、病情稳定时间等临床一般情况。结果:两组患者在上述方面比较,差异均具有统计学意义(P<0.05),CBP组优于常规组。结论:在治疗SAP患者的过程中,应积极加行CBP治疗措施,可提高临床疗效,改善患者预后。     

连续性血液净化在重症急性胰腺炎患者中应用的临床疗效观察

目的：观察连续性血液净化（CBP）在重症急性胰腺炎（SAP）患者中应用的临床疗效,探讨提高SAP临床疗效的治疗措施方法：选择在我科就诊的SAP患者64例,根据患者自愿的原则,分为常规组和CBP组,常规组采用内科常规治疗措施,CBP组在常规治疗的基础上加行CBP治疗,比较两组患者治疗中血清淀粉酶的动态改变、治疗第5天各项生化指标及APACHEII评分、病情稳定时间等临床一般情况。结果：两组患者在上述方面比较,差异均具有统计学意义（P〈O．05）,CBP组优于常规组。结论：在治疗SAP患者的过程中,应积极加行CBP治疗措施,可提高临床疗效,改善患者预后。     

Increased Risk of Acute Pancreatitis in Patients with Chronic Hemodialysis: A 4-Year Follow-Up Study

Background

The risk of acute pancreatitis in patients on long-term peritoneal dialysis is higher as compared to the general population. However, the relationship between long-term hemodialysis and acute pancreatitis has never been established.

Objectives

We investigated the incidence of acute pancreatitis among patients on long-term hemodialysis in Taiwan to evaluate if there is a higher risk of acute pancreatitis in comparison to the general population.

Methods

We utilized a National Health Insurance (NHI) claims data sample containing one million beneficiaries. We followed all adult beneficiaries from January 1, 2007 until December 31, 2010 to see if they had been hospitalized for acute pancreatitis during this period. We further identified patients on chronic hemodialysis and compared their risk of acute pancreatitis with the general population.

Results

This study included 2603 patients with long-term hemodialysis and 773,140 patients without hemodialysis. After controlling for age, gender, Charlson Comorbidity Index Score, geographic region, socioeconomic status and urbanization level, the adjusted hazard ratio was 3.44 (95% Confidence interval, 2.5–4.7).

Conclusions

The risk of acute pancreatitis in patients on long-term hemodialysis is significantly higher in comparison to the general population.     

双氯灭痛胶浆对重症急性胰腺炎大鼠的治疗作用机制

目的:研究双氯灭痛胶浆对大鼠重症急性胰腺炎(SAP)的治疗作用及机制探讨.方法:将大鼠随机分成双氯灭痛胶浆治疗组(Ds)、重症急性胰腺炎组(SAP)和正常对照组(N),术后分别于12、24和36h处死,观察血清淀粉酶、SOD、CAT、NO、丙二醛(MDA)、核因子κB(NF-κB)、及胰腺大体病理及光镜下病理变化.结果:治疗组的淀粉酶、NF-κB、NO、MDA、胰腺组织的Hughes评分均明显降低、SOD、CAT、明显升高(P＜0.05).结论:双氯灭痛胶浆对大鼠SAP有治疗作用,其作用机制可能与抑制NF-κB等前致炎物质的释放,清除自由基和抗脂质过氧化反应,抑制胰腺组织中的中性粒细胞的浸润及其活化程度有关.