Criteria for the diagnosis and severity stratification of acute pancreatitis

Recent diagnostic and therapeutic progress for severe acute pancreatitis(SAP)remarkably decreased the casemortality rate.To further decrease the mortality rate of SAP,it is important to precisely evaluate the severity at an early stage,and initiate appropriate treatment as early as possible.Research Committee of Intractable Diseases of the Pancreas in Japan developed simpler criteria combining routinely available data with clinical signs.Severity can be evaluated by laboratory examinations or by clinical signs,reducing the defect values of the severity factors.Moreover,the severity criteria considered laboratory/clinical severity scores and contrastenhanced computed tomography(CE-CT)findings as independent risk factors.Thus,CE-CT scans are not necessarily required to evaluate the severity of acute pancreatitis.There was no fatal case in mild AP diagnosed by the CE-CT severity score,whereas case-mortality rate in those with SAP was 14.8%.Case-mortality of SAP that fulfilled both the laboratory/clinical and the CE-CT severity criteria was 30.8%.It is recommended,therefore,to perform CE-CT examination to clarify the prognosis in those patients who were diagnosed as SAP by laboratory/clinical severity criteria.Because the mortality rate of these patients with SAP is high,such patients should be transferred to advanced medical units.

Consensus of primary care in acute pancreatitis in Japan

在日本的尖锐胰腺炎的发生正在增加并且每百万张人口从 187 ～ 347 个盒子。盒子命运是 0.2% 为对温和中等，并且 9.0% 为在在 2003 的日本的严重尖锐胰腺炎。在日本的胰腺炎的专家做了与尖锐胰腺炎在病人的早管理集中于实际方面的这个文件。尖锐胰腺炎和严厉层化的正确诊断应该为尖锐胰腺炎的诊断用标准在所有病人被做并且多，因素得分系统尽早由胰的难处理的疾病的研究委员会求婚了。与尖锐胰腺炎诊断的所有病人应该在医院里被管理。血压监视，脉搏和呼吸率，体温，时时尿的体积，和血氧饱和水平在如此的病人的管理是必要的。早精力旺盛的静脉内的水和具有最前的重要性稳定循环动力学。有鸦片剂的足够的疼痛地势也是重要的。在严重尖锐胰腺炎，在一个早阶段的抗菌素的预防静脉内的管理被推荐。一旦尖锐胰腺炎的诊断被证实，朊酶禁止者的管理应该被开始。如果没有肠塞痛并且胃肠的流血的清楚的症状，从早舞台用非肠道的营养喂的肠内的联合被推荐。有严重尖锐胰腺炎的病人应该尽早被转移到 ICU 执行象朊酶的连续地区性的动脉的注入那样的特殊措施禁止者和抗菌素，和连续牙齿过敏过滤。日本政府为难处理的疾病作为关于措施的研究的工程之一为严重尖锐胰腺炎盖住医疗保健开销。

Effect of endogenous cholecystokinin on the course of acute pancreatitis in rats

AIM: To examine the effects of pancreatic rest, stimulation and rest/stimulation on the natural course of recovery after acute pancreatitis. METHODS: Acute hemorrhagic pancreatitis(AP) was induced in male rats by intraductal infusion of 40 μl/100 g body weight of 3% sodium taurocholate. All rats took food ad libitum. At 24 h after induction of AP, rats were divided into four groups: control(AP-C), pancreas rest(AP-R), stimulation(AP-S), and rest/stimulation(AP-R/S). Rats in the AP-C, AP-R and AP-S groups received oral administration of 2 ml/kg body weight saline, cholecystokinin(CCK)-1 receptor antagonist, and endogenous CCK release stimulant, respectively, twice daily for 10 d, while those in the AP-R/S group received twice daily CCK-1 receptor antagonist for the first 5 d followed by twice daily CCK release stimulant for 5 d. Rats without any treatment were used as control group(Control). Biochemical andhistological changes in the pancreas, and secretory function were evaluated on day 12 at 24 h after the last treatment. RESULTS: Feeding ad libitum(AP-C) delayed biochemical, histological and functional recovery from AP. In AP-C rats, bombesin-stimulated pancreatic secretory function and HOMA-β-cell score were significantly lower than those in other groups of rats. In AP-R rats, protein per DNA ratio and pancreatic exocrine secretory function were significantly low compared with those in Control rats. In AP-S and AP-R/S rats, the above parameters recovered to the Control levels. Bombesinstimulated pancreatic exocrine response in AP-R/S rats was higher than in AP-S rats and almost returned to control levels. In the pancreas of AP-C rats, destruction of pancreatic acini, marked infiltration of inflammatory cells, and strong expression of α-smooth muscle actin, tumor necrosis factor-α and interleukin-1β were seen. Pancreatic rest reversed these histological alterations, but not atrophy of pancreatic acini and mild infiltration of inflammatory cells. In AP-S and AP-R/S rats, the pancreas showed almost normal architecture. CONCLUSION: The favorable treatment strategy for AP is to keep the pancreas at rest during an early stage followed by pancreatic stimulation by promoting endogenous CCK release.

Autoimmune pancreatitis with IgG4-positive plasma cell infiltration in salivary glands and biliary tract

A 62-year-old male was referred to our hospital because of liver dysfunction, diffuse pancreatic swelling, and trachelophyma. At admission, the patient was free of pain.Physical examination showed enlarged and palpable bilateral submandibular masses, but no palpable mass or organomegaly in the abdomen. Laboratory findings were as follows: total protein 90 g/L with γ-globulin of 37.3% (33 g/L), total bilirubin 4 mg/L, aspartate aminotransferase 39 IU/L, alanine aminotransferase 67 IU/L, γ-glutamyl transpeptidase 1 647 IU/L, and amylase 135 IU/L. Autoantibodies were negative, and tumor markers were within the normal range. Serum IgG4 level was markedly elevated (18 900 mg/L). Computed tomography (CT) showed diffuse swelling of the pancreas and dilatation of both common and intra-hepatic bile ducts. Endoscopic retrograde pancreatography (ERP) revealed diffuse irregular and narrow main pancreatic duct and stenosis of the lower common bile duct. Biopsy specimens from the pancreas, salivary gland and liver showed marked periductal IgG4-positive plasma cell infiltration with fibrosis. We considered this patient to be autoimmune pancreatitis (AIP) with fibrosclerosis of the salivary gland and biliary tract, prescribed prednisolone at an initial dose of 40 mg/d. Three months later, the laboratory data improved almost to normal. Abdominal CT reflected prominent improvement in the pancreatic lesion. Swelling of the salivary gland also improved. At present, the patient is on 10 mg/d of prednisolone without recurrence of the pancreatitis. We present here a case of AIP with fibrosclerosis of salivary gland and biliary tract.

Long-term treatment with proton pump inhibitor is associated with undesired weight gain

AIM:To examine the effects of long-term proton pump inhibitor (PPI) therapy on body weight (BW) and body mass index (BMI) in patients with gastroesophageal reflux disease (GERD).METHODS: The subjects were 52 patients with GERD and 58 sex-and age-matched healthy controls. GERD patients were treated with PPI for a mean of 2.2 years (range, 0.8-5.7 years), and also advised on lifestyle modifications (e.g. selective diet, weight management). BW, BMI and other parameters were measured at baseline and end of study.RESULTS: Twenty-four GERD patients were treated daily with 10 mg omeprazole, 12 with 20 mg omeprazole, 8 with 10 mg rabeprazole, 5 with 15 mg lansoprazole, and 3 patients with 30 mg lansoprazole. At baseline, there were no differences in BW and BMI between reflux patients and controls. Patients with GERD showed increases in BW (baseline: 56.4±10.4 kg, end: 58.6±10.8 kg, mean±SD, P<0.0001) and BMI (baseline: 23.1±3.1 kg/m2, end: 24.0±3.1 kg/m2, P<0.001), but no such changes were noted in the control group. Mean BW increased by 3.5 kg (6.2% of baseline) in 37 (71%) reflux patients but decreased in only 6 (12%) patients during treatment.CONCLUSION: Long-term PPI treatment was associated with BW gain in patients with GERD. Reflux patients receiving PPI should be encouraged to manage BW through lifestyle modifi cations.