Effects of disease severity and necrosis on pancreatic dysfunction after acute pancreatitis

AIM:To evaluate the effects of disease severity and necrosis on organ dysfunctions in acute pancreatitis(AP).METHODS:One hundred and nine patients treated as AP between March 2003 and September 2007 with at least 6 mo follow-up were included.Patients were classified according to severity of the disease,necrosis ratio and localization.Subjective clinical evaluation and fecal pancreatic elastase-Ⅰ(FPE-Ⅰ)were used for exocrine dysfunction evaluation,and oral glucose tolerance test was completed for endocrine dysfunction.The correlation of disease severity,necrosis ratio and localization with exocrine and endocrine dysfunction were investigated.RESULTS:There were 58 male and 51 female patients,and mean age was 56.5±15.7.Of the patients,35.8%had severe AP(SAP)and 27.5%had pancreatic necrosis.Exocrine dysfunction was identified in 13.7%of the patients[17.9%were in SAP,11.4%were in mild AP(MAP)]and 34.7%of all of the patients had endocrine dysfunction(56.4%in SAP and 23.2%in MAP).In patients with SAP and necrotizing AP(NAP),FPE-Ⅰlevels were lower than the others(P<0.05 and0.001 respectively)and in patients having pancreatic head necrosis or near total necrosis,FPE-1 levels were lower than 200μg/g stool.Forty percent of the patients who had undergone necrosectomy developed exocrine dysfunction.Endocrine dysfunction was more significant in patients with SAP and NAP(P<0.001).All of the patients in the necrosectomy group had endocrine dysfunction.CONCLUSION:Patients with SAP,NAP,pancreatic head necrosis and necrosectomy should be followed for pancreatic functions.

Influence of splanchnic vascular infusion on the content of endotoxins in plasma and the translocation of intestinal bacteria in rats with acute hemorrhage necrosis pancreatitis

The main reason for the death of the patient with acute hemorrhage necrosis pancreatitis (AHNP) is pancreatic infection and multi-organ failure caused by endotoxemia and intestinal bacterial translocation[1-7]. However, the pathogenesis of endotoxemia and intestinal bacterial translocation remains a question[8-10]; moreover, no effective method of prevention and cure for it has been found till now[11 -15] In the present study, we infused low dose dopamine and low molecular weight dextran through the catheters to abdominal aorta and portal vein, and observed its influence on the endotoxin concentration in plasma and the rate of translocation of intestinal bacteria in AHNP rats.

Infected pancreatic necrosis: Not necessarily a late event in acute pancreatitis

It is widely believed that infection of pancreatic necrosis is a late event in the natural course of acute pancreatitis. This paper discusses the available data on the timing of pancreatic infection. It appears that infected pancreatic necrosis occurs early in almost a quarter of patients. This has practical implications for the type, timing and duration of preventive strategies used in these patients. There are also implications for the classification of severity in patients with acute pancreatitis. Given that the main determinants of severity are both local and systemic complications and that they can occur both early and late in the course of acute pancreatitis, the classification of severity should be based on their presence or absence rather than on when they occur. To do otherwise, and in particular overlook early infected pancreatic necrosis, may lead to a misclassification error and fallacies of clinical studies in patients with acute pancreatitis.

Functional Role of Micro RNA-19b in Acinar Cell Necrosis in Acute Necrotizing Pancreatitis

The expression of micro RNA-19b（mi R-19b） in acute necrotizing pancreatitis（ANP） and its functional role in acinar cell necrosis of SD rats were investigated. Twelve SD rats were divided into two groups randomly, including control group and ANP group. The rat ANP models were established by intraperitoneal injection of L-arginine（2400 mg/kg body weight）, and equal volume of 0.9% Na Cl was injected in the control group. Mi RNA chip assay was performed to examine the expression of mi RNAs in the pancreas in two different groups. Besides, to further explore the role of mi R-19 b in ANP in vitro, taurolithocholic acid 3-sulfate disodium salt（TLC-S）（200 μmol/L） was administrated to treat the rat pancreatic acinar cell line, AR42 J, for establishing the ANP cells model. The quantitative real-time PCR（q RT-PCR） was adopted to measure the mi R-19 b expression. Moreover, the mimic mi RNA, mi RNA antisense oligonucleotide（AMO） and control vector were used to transfect AR42 J cells, the expression of mi R-19 b was confirmed by q RT-PCR and the necrotizing rate of AR42 J cells was detected with AO/EB method. The expression of mi R-19 b was significantly higher in ANP group than in control group as displayed by the mi RNA chip assay. Furthermore, after inducing necrosis of AR42 J cells in vitro, the expression of mi R-19 b was significantly increased by 2.51±0.14 times in comparison with the control group. As revealed by q RT-PCR assay, the expression of mi R-19 b was 5.94±0.95 times higher in the mimic mi RNA group than in the control vector group, companied with an obviously increased acinar cell necrotizing rate（50.3%±1.5% vs. 39.6%±2.3%, P〈0.05）. Moreover, the expression of mi R-19 b in the mi RNA AMO group was 0.38±0.15 times lower than in the control vector group, and the cell necrosis rate was much lower accordingly（23.1%±3.3% vs. 39.6%±2.3%, P〈0.05）. Besides, there was no significant difference between the control vector cells and the cells without treatment（P〈0.05）. The expression of mi R-19 b was significantly induced in ANP. In addition, up-regulation of mi R-19 b could promote the necrosis of pancreatic acinar cells and mi R-19 b deficiency could decrease the rate of pancreatic acinar cell necrosis.

Risk factors of infected pancreatic necrosis secondary to severe acute pancreatitis

BACKGROUND： Severe acute pancreatitis（SAP） remains a clinical challenge with considerable morbidity and mortality.An early identification of infected pancreatic necrosis（IPN）, a life-threatening evolution secondary to SAP, is obliged for a more preferable prognosis. Thus, the present study was conducted to identify the risk factors of IPN secondary to SAP. METHODS： The clinical data of patients with SAP were retrospectively analyzed. Univariate and multivariate logistic regression analyses were sequentially performed to assess the associations between the variables and the development of IPN secondary to SAP. A receiver operating characteristic（ROC） curve was created for each of the qualified independent risk factors. RESULTS： Of the 115 eligible patients, 39（33.9%） progressed to IPN, and the overall in-hospital mortality was 11.3%（13/115）.The early enteral nutrition（EEN）（P=0.0092, OR=0.264）, maximum intra-abdominal pressure（IAP）（P=0.0398, OR=1.131）and maximum D-dimer level（P=0.0001, OR=1.006） in the first three consecutive days were independent risk factors associated with IPN secondary to SAP. The area under ROC curve（AUC） was 0.774 for the maximum D-dimer level in the first three consecutive days and the sensitivity was 90% and the specificity was 58% at a cut-off value of 933.5 μg/L; the AUC was 0.831 for the maximum IAP in the first three consecutive days and the sensitivity was 95% and specificity was 58%at a cut-off value of 13.5 mm Hg. CONCLUSIONS： The present study suggested that the maximum D-dimer level and/or maximum IAP in the first three consecutive days after admission were risk factors of IPN secondary to SAP; an EEN might be helpful to prevent the progression of IPN secondary to SAP.

Pancreatic necrosis and severity are independent risk factors for pancreatic endocrine insufficiency after acute pancreatitis: A long-term follow-up study

BACKGROUND Pancreatic endocrine insufficiency after acute pancreatitis(AP) has drawn increasing attention in recent years.AIM To assess the impact of risk factors on the development of pancreatic endocrine insufficiency after AP.METHODS This retrospective observational long-term follow-up study was conducted in a tertiary hospital. Endocrine function was evaluated by the oral glucose tolerance test. The data, including age, sex, body mass index, APACHE II score, history of smoking and drinking, organ failure, pancreatic necrosis, debridement of necrosis(minimally invasive and/or open surgery), and time interval, were collected from the record database.RESULTS A total of 361 patients were included in the study from January 1, 2012 to December 30, 2018. A total of 150(41.6%) patients were diagnosed with dysglycemia(including diabetes mellitus and impaired glucose tolerance), while211(58.4%) patients had normal endocrine function. The time intervals(mo) of the above two groups were 18.73 ± 19.10 mo and 31.53 ± 27.27 mo, respectively(P= 0.001). The morbidity rates of pancreatic endocrine insufficiency were 46.7%,28.0%, and 25.3%, respectively, in the groups with different follow-up times. The risk factors for pancreatic endocrine insufficiency after AP were severity(odds ratio [OR] = 3.489;95% confidence interval [CI]: 1.501-8.111;P = 0.004) and pancreatic necrosis(OR = 4.152;95%CI: 2.580-6.684;P = 0.001).CONCLUSION Pancreatic necrosis and severity are independent risk factors for pancreatic endocrine insufficiency after AP. The area of pancreatic necrosis can affect pancreatic endocrine function.

Extrapancreatic necrosis volume:A new tool in acute pancreatitis severity assessment?

BACKGROUND Many scores have been suggested to assess the severity of acute pancreatitis upon onset.The extrapancreatic necrosis volume is a novel,promising score that appears to be superior to other scores investigated so far.AIM To evaluate the discriminatory power of extrapancreatic necrosis volume to identify severe cases of acute pancreatitis.METHODS A total of 123 patients diagnosed with acute pancreatitis at Institute of Gastroenterology and Hepatology,St Spiridon Hospital between January 1,2017 and December 31,2019 were analyzed retrospectively.Pancreatitis was classified according to the revised Atlanta classification(rAC)as mild,moderate,or severe.Severity was also evaluated by computed tomography and classified according to the computed tomography severity index(CTSI)and the modified CTSI(mCTSI).The results were compared with the extrapancreatic volume necrosis to establish the sensitivity and specificity of each method.RESULTS The CTSI and mCTSI imaging scores and the extrapancreatic necrosis volume were highly correlated with the severity of pancreatitis estimated by the rAC(r=0.926,P<0.001 and r=0.950,P<0.001;r=0.784,P<0.001,respectively).The correlation of C-reactive protein with severity was positive but not as strong,and was not significant(r=0.133,P=0.154).The best predictor for the assessment of severe pancreatitis was the extrapancreatic necrosis volume[area under the curve(AUC)=0.993;95%confidence interval(CI):0.981-1.005],with a 99.5%sensitivity and 99.0%specificity at a cutoff value of 167 mL,followed by the mCTSI 2007 score(AUC=0.972;95%CI:0.946-0.999),with a 98.0%sensitivity and 96.5%specificity,and the CTSI 1990 score(AUC=0.969;95%CI:0.941-0.998),with a 97.0%sensitivity and 95.0%specificity.CONCLUSION Radiological severity scores correlate strongly and positively with disease activity.Extrapancreatic necrosis volume shows the best diagnostic accuracy for severe cases.

Complementary comments on diagnosis,severity and prognosis prediction of acute pancreatitis

The radiological differential diagnosis of acute pancreatitis includes diffuse pancreatic lymphoma,diffuse autoimmune pancreatitis and groove located mass lesions that may mimic groove pancreatitis.Dual energy computed tomography and diffusion weighted magnetic resonance imaging are useful in the early diagnosis of acute pancreatitis,and dual energy computed tomography is also useful in severity assessment and prognosis prediction.Walled off necrosis is an important complication in terms of prognosis,and it is important to know its radiological findings and distinguish it from pseudocyst.

Early prediction and prevention of infected pancreatic necrosis

Approximately 20%-30%of patients with acute necrotizing pancreatitis develop infected pancreatic necrosis(IPN),a highly morbid and potentially lethal complication.Early identification of patients at high risk of IPN may facilitate appropriate preventive measures to improve clinical outcomes.In the past two decades,several markers and predictive tools have been proposed and evaluated for this purpose.Conventional biomarkers like C-reactive protein,procalcitonin,lymphocyte count,interleukin-6,and interleukin-8,and newly developed biomarkers like angiopoietin-2 all showed significant association with IPN.On the other hand,scoring systems like the Acute Physiology and Chronic Health Evaluation II and Pancreatitis Activity Scoring System have also been tested,and the results showed that they may provide better accuracy.For early prevention of IPN,several new therapies were tested,including early enteral nutrition,anti-biotics,probiotics,immune enhancement,etc.,but the results varied.Taken together,several evidence-supported predictive markers and scoring systems are readily available for predicting IPN.However,effective treatments to reduce the incidence of IPN are still lacking apart from early enteral nutrition.In this editorial,we summarize evidence concerning early prediction and prevention of IPN,providing insights into future practice and study design.A more homo-geneous patient population with reliable risk-stratification tools may help find effective treatments to reduce the risk of IPN,thereby achieving individualized treatment.

Early versus delayed necrosectomy in pancreatic necrosis:A population-based cohort study on readmission,healthcare utilization,and in-hospital mortality

BACKGROUND Acute necrotizing pancreatitis is a severe and life-threatening condition.It poses a considerable challenge for clinicians due to its complex nature and the high risk of complications.Several minimally invasive and open necrosectomy procedures have been developed.Despite advancements in treatment modalities,the optimal timing to perform necrosectomy lacks consensus.AIM To evaluate the impact of necrosectomy timing on patients with pancreatic necrosis in the United States.METHODS A national retrospective cohort study was conducted using the 2016-2019 Nationwide Readmissions Database.Patients with non-elective admissions for pancreatic necrosis were identified.The participants were divided into two groups based on the necrosectomy timing:The early group received intervention within 48 hours,whereas the delayed group underwent the procedure after 48 hours.The various intervention techniques included endoscopic,percutaneous,or surgical necrosectomy.The major outcomes of interest were 30-day readmission rates,healthcare utilization,and inpatient mortality.RESULTS A total of 1309 patients with pancreatic necrosis were included.After propensity score matching,349 cases treated with early necrosectomy were matched to 375 controls who received delayed intervention.The early cohort had a 30-day readmission rate of 8.6% compared to 4.8%in the delayed cohort(P=0.040).Early necrosectomy had lower rates of mechanical ventilation(2.9%vs 10.9%,P<0.001),septic shock(8%vs 19.5%,P<0.001),and in-hospital mortality(1.1%vs 4.3%,P=0.01).Patients in the early intervention group incurred lower healthcare costs,with median total charges of $52202 compared to$147418 in the delayed group.Participants in the early cohort also had a relatively shorter median length of stay(6 vs 16 days,P<0.001).The timing of necrosectomy did not significantly influence the risk of 30-day readmission,with a hazard ratio of 0.56(95%confidence interval:0.31-1.02,P=0.06).CONCLUSION Our findings show that early necrosectomy is associated with better clinical outcomes and lower healthcare costs.Delayed intervention does not significantly alter the risk of 30-day readmission.

Severe acute pancreatitis： pathogenesis, diagnosis and surgical management

BACKGROUND： Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology.DATA SOURCES： Studies published between 1st January 1991 and 31st December 2015 were identified with Pub Med, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings： “acute pancreatitis, necrosis, mortality, pathogenesis, incidence” and the terms “open necrosectomy and minimally invasive necrosectomy”.The National Institute of Clinical Excellence（NICE） Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks.RESULTS： The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology,acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed.The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach.CONCLUSIONS： Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis （SAP）. An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as e^ective as multifactorial scoring systems （MFSS） at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen （BUN）, creatinine, matrix metalloproteinase-9 （MMP-9） and serum amyloid A （SAA） have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis （PN）, infected PN （IPN） and mortality.

Bedside index for severity in acute pancreatitis:comparison with other scoring systems in predicting severity and organ failure

BACKGROUND:The early identification of severe acute pancreatitis is important for the management and for improving outcomes.The bedside index for severity in acute pancreatitis(BISAP)has been considered as an accurate method for risk stratification in patients with acute pancreatitis.This study aimed to evaluate the comparative usefulness of the BISAP.METHODS:We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007to December 2010.BISAP,APACHE-II,Ranson criteria,and CT severity index(CTSI)of all patients were calculated.We stratified the number of patiants with severe pancreatitis,pancreatic necrosis,and organ failure as well as the number of deaths by BISAP score.We used the area under the receiveroperating curve(AUC)to compare BISAP with other scoring systems,C-reactive protein(CRP),hematocrit,and body mass index(BMI)with regard to prediction of severe acute pancreatitis,necrosis,organ failure,and death.RESULTS:Of the 303 patiants,31(10.2%)were classified as having severe acute pancreatitis.Organ failure occurred in 23(7.6%)patients,pancreatic necrosis in 40(13.2%),and death in6(2.0%).A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis,organ failure,and mortality.AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86,respectively,which were similar to those for APACHE-II(0.80,0.87)and Ranson criteria(0.74,0.74)and greater than AUCs for CTSI(0.67,0.42).The AUC for organ failure predicted by BISAP,APACHE-II,Ranson criteria,and CTSI was 0.93,0.95,0.84 and 0.57,respectively.AUCs for BISAP predicting severity,organ failure,and death were greater than those for CRP(0.69,0.80,0.72),hematocrit(0.45,0.35,0.14),and BMI(0.41,0.47,0.17).CONCLUSION:The BISAP predicts severity,death,and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria,CTSI,CRP,hematocrit,and BMI.

Advances in prognostic factors in acute pancreatitis:a mini-review

BACKGROUND:Early assessment of the severity of acute pancreatitis is essential to the proper management of the disease.It is dependent on the criteria of the Atlanta classification system.DATA SOURCES:PubMed search of recent relevant articles was performed to identify information about the severity and prognosis of acute pancreatitis.RESULTS:The scoring systems included the Ranson’s or Glasgow’s criteria ≥3,the APACHE II classification system ≥8,and the Balthazar’s criteria ≥4 according to the computed tomography enhanced scanning findings.The single factors on admission included age >65 years,obesity,hemoconcentration(>44%),abnormal chest X-ray,creatinine >2 mg/dl,C-reactive protein>150 mg/dl,procalcitonin >1.8 ng/ml,albumin <2.5 mg/dl,calcium <8.5 mg/dl,early hyperglycemia,increased intra-abdominal pressure,macrophage migration inhibitory factor,or a combination of IL-10 >50 pg/ml with calcium <6.6 mg/dl.CONCLUSION:The prediction of the severity of acute pancreatitis is largely based on well defined multiple factor scoring systems as well as several single risk factors.

Severe acute pancreatitis: Clinical course and management

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.

Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification

BACKGROUND: Recent international multidisciplinary consultation proposed the use of local (sterile or infected pancreatic necrosis) and/or systemic determinants (organ failure) in the stratification of acute pancreatitis. The present study was to validate the moderate severity category by international multidisciplinary consultation definitions. METHODS: Ninety-two consecutive patients with severe acute pancreatitis (according to the 1992 Atlanta classification) were classified into (i) moderate acute pancreatitis group with the presence of sterile (peri-) pancreatic necrosis and/or transient organ failure; and (ii) severe/critical acute pancreatitis group with the presence of sterile or infected pancreatic necrosis and/ or persistent organ failure. Demographic and clinical outcomes were compared between the two groups. RESULTS: Compared with the severe/critical group (n=59), the moderate group (n=33) had lower clinical and computerized tomographic scores (both P<0.05). They also had a lower incidence of pancreatic necrosis (45.5% vs 71.2%, P=0.015), infection (9.1% vs 37.3%, P=0.004), ICU admission (0% vs 27.1%, P=0.001), and shorter hospital stay (15 +/- 5 vs 27 +/- 12 days; P<0.001). A subgroup analysis showed that the moderate group also had significantly lower ICU admission rates, shorter hospital stay and lower rate of infection compared with the severe group (n=51). No patients died in the moderate group but 7 patients died in the severe/critical group (4 for severe group). CONCLUSIONS: Our data suggest that the definition of moderate acute pancreatitis, as suggested by the international multidisciplinary consultation as sterile (pen-) pancreatic necrosis and/or transient organ failure, is an accurate category of acute pancreatitis.

Hemoconcentration is a poor predictor of severity in acute pancreatitis

AIM： To determine whether the hematocrit （Hct） at admission or at 24 h after admission was associated with severe acute pancreatitis （AP）, organ failure （OF）, and pancreatic necrosis. METHODS： A total of 336 consecutive patients with a first AP episode were studied. Etiology, Hct values at admission and at 24 h, development of severe AP according to Atlanta＇s criteria, pancreatic necrosis, OF and mortality were recorded. Hemoconcentration was defined as Hct level 〉44% for males and 〉40% for females. The t-test and ;x^2 test were used to assess the association of hemoconcentration to the severity, necrosis and OF. Diagnostic accuracy was also determined. RESULTS： Biliary disease was the most frequent etiology （n = 148）. Mean Hct levels at admission were 41±6% for females and 46±7% for males （P〈0.01）. Seventyeight （23%） patients had severe AP, and OF developed in 45 （13%） patients. According to contrast-enhanced computed tomography scan, 36% （54/150） patients showed pancreatic necrosis. Hct levels were elevated in 58% （55/96） and 61% （33/54） patients with interstitial and necrotizing pancreatitis, respectively. Neither Hct levels at admission nor hemoconcentration at 24 h were associated with the severity, necrosis or OF. Sensitivity, specificity and positive predictive values for both determinations were very low; and negative predictive values were between 61% and 86%, being the highest value for OF. CONCLUSION： Hct is not a useful marker to predict a worse outcome in acute pancreatitis. In spite of the high negative predictive value of hemoconcentration, the prognosis gain is limited due to an already high incidence of mild disease.

Magnetic resonance imaging for acute pancreatitis

Acute pancreatitis is characterized by acute chemical injury of the pancreatic parenchyma and peripancreatic tissue.The increased frequency of death in acute pancreatitis is directly correlated with the degree and progress of pancreatic necrosis.Moreover,the occurrence of some local complications in acute pancreatitis,such as pancreatic hemorrhage,peripancreatic abscess or large pseudocyst,and pseudoaneurysm,could influence the choice of treatment for these patients.Magnetic resonance imaging(MRI) can be used to help evaluate the presence and degree of pancreatic necrosis,and is crucial for identifying complications of acute pancreatitis and predicting prognosis.The purpose of this article is to describe MRI techniques for acute pancreatitis,to review the spectrum of pancreatic and peripancreatic patterns,as well as to survey various complications secondary to acute pancreatitis on MRI.The role of MRI in the initial evaluation and staging of acute pancreatitis is emphasized.

Relaxin prevents the development of severe acute pancreatitis

AIM： TO investigate the severity of acute pancreatitis （AP） is associated to the intensity of leukocyte activation, inflammatory up-regulation and microcirculatory disruption associated to ischernia-reperfusion injury. Hicrovascular integrity and inhibition of pro-inflammatory mediators are key-factors in the evolution of AP. Relaxin is an insulin-like hormone that has been attributed vasorelaxant properties via the nitric oxide pathway while behaving as a glucocorticoid receptor agonist. METHODS： AP was induced by the bilio-pancreatic duct-outlet-exclusion closed-duodenal-loops model. Treatment with relaxin was done at different timepoints. Nitric oxide synthase inhibition by L-NAME and glucocorticoid receptor （GR） blockage by mifepristone was considered. AP severity was assessed by biochemical and histopathological analyses. RESULTS： Treatment with relaxin reduced serum amylase, lipase, C-reactive protein, IL-6, IL-10, hsp72, LDH and 8-isoprostane as well as pancreatic and lung myeloperoxidase. Acinar and fat necrosis, hemorrhage and neutrophil infiltrate were also decreased. ATP depletion and ADP/ATP ratio were reduced while caspases 2-3-8 and 9 activities were increased. L-NAME and mifepristone decreased the efficiency of relaxin. CONCLUSION： Relaxin resulted beneficial in the treatment of AP combining the properties of a GR agonist while preserving the microcirculation and favoring apoptosis over necrosis.

Acute pancreatitis:The stress factor

Acute pancreatitis is an inflammatory disorder of the pancreas that may cause life-threatening complications.Etiologies of pancreatitis vary,with gallstones accounting for the majority of all cases,followed by alcohol.Other causes of pancreatitis include trauma,ischemia,mechanical obstruction,infections,autoimmune,hereditary,and drugs.The main events occurring in the pancreatic acinar cell that initiate and propagate acute pancreatitis include inhibition of secretion,intracellular activation of proteases,and generation of inflammatory mediators.Small cytokines known as chemokines are released from damaged pancreatic cells and attract inflammatory cells,whose systemic action ultimately determined the severity of the disease.Indeed,severe forms of pancreatitis may result in systemic inflammatory response syndrome and multiorgan dysfunction syndrome,characterized by a progressive physiologic failure of several interdependent organ systems.Stress occurs when homeostasis is threatened,and stressors can include physical or mental forces,or combinations of both.Depending on the timing and duration,stress can result in beneficial or harmful consequences.While it is well established that a previous acute-short-term stress decreases the severity of experimentally-induced pancreatitis,the worsening effects of chronic stress on the exocrine pancreas have received relatively little attention.This review will focus on the influence of both prior acute-short-term and chronic stress in acute pancreatitis.