Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.

Nutrition in acute pancreatitis

Acute pancreatitis(AP)has varying severity,and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions.These patients are at risk of malnutrition.There is no proven pharmacotherapy for AP,however,apart from fluid resuscitation,analgesics,and organ support,nutrition plays an important role in the management of AP.Oral or enteral nutrition(EN)is the preferred route of nutrition in AP,however,in a subset of patients,parenteral nutrition is required.EN has various physiological benefits and decreases the risk of infection,intervention,and mortality.There is no proven role of probiotics,glutamine supplementation,antioxidants,and pancreatic enzyme replacement therapy in patients with AP.

COVID-19 in patients with pre-existing chronic liver disease–predictors of outcomes

Coronavirus disease 2019(COVID-19)has affected patients with pre-existing chronic liver disease(CLD)in various ways.The maximum impact was seen on patients with underlying cirrhosis who have shown to have poor clinical outcomes in the form of increased risk of hepatic decompensation,acute-onchronic liver failure,and even mortality.It is of paramount importance to identify various factors which are associated with unfavorable outcomes for prognostication and making informed management strategy.Many factors have been evaluated in different studies in patients with underlying CLD.Some of these factors include the severity of underlying chronic liver disease,comorbid conditions,age,and severity of COVID-19.Overall,the outcomes are not favorable in patients with cirrhosis as evidenced by data from various studies.The main purpose of this review is to identify the predictors of adverse clinical outcomes including mortality in patients with CLD for risk stratification,prognostication,and appropriate clinical management.

Plasma cathepsin L:A prognostic marker for pancreatic cancer

AIM:To assess the prognostic significance of cathepsin L,a cysteine protease that degrades the peri-tumoral tissue,in patients with pancreatic cancer.METHODS:Plasma samples from 127 pancreatic cancer patients were analyzed for cathepsin L levels by ELISA.Out of these patients,25 underwent surgeryand their paraffin-embedded tissue was analyzed for cathepsin L expression by immunohistochemistry.Survival of patients and clinicopathological parameters was correlated with cathepsin L expression in plasma and tissue using appropriate statistical analysis.RESULTS:The mean(±SD)cathepsin L in plasma samples of pancreatic cancer patients was 5.98±2.5ng/m L that was significantly higher compared to the levels in healthy controls(3.83±0.45)or chronic pancreatitis patients(3.97±1.06).Using ROC curve,a cut-off level of 5.0 ng/m L was decided for survival analysis.Elevated plasma levels of cathepsin L were found to be associated with poor prognosis(P=0.01)in multivariate analysis.The plasma levels of the protease decreased after surgery.Though no significant correlation was seen between plasma and tissue expression of this protease,a trend did emerge that high cathepsin L expression in tissue correlated with its high levels in plasma.CONCLUSION:Cathepsin L levels in plasma of pancreatic cancer patients may be used as a potential prognostic marker for the disease.

Special Considerations in the Management of Autoimmune Hepatitis in COVID-19 Hotspots:A Review

The ongoing coronavirus disease-2019(COVID-19)pandemic has necessitated special considerations in the management of diseases.The way presence of pre-existing diseases or treatment for it predisposes to,alters course of,and changes the management of COVID-19,is of relevance and is being extensively studied.Autoimmune hepatitis(AIH)is unique in that it is an autoimmune disease mandating treatment with immunosuppressive drugs,as well as a liver disease with potential for varying degrees of underlying fibrosis.The use of immunosuppressive drugs could alter the risk of acquiring COVID-19,the clinical course and severity of COVID-19 and the degree of underlying liver fibrosis could alter the clinical outcomes of patients with COVID-19.In this review,we try to summarize key areas relevant in understanding and improving the clinical care of patients with AIH in the current pandemic.Special considerations required in the management of patients with AIH in COVID-19 hotspots have been outlined based on the current evidence.