Study progress on mechanism of severe acute pancreatitis complicated with hepatic injury

Study on the action mechanism of inflammatory mediators generated by the severe acute pancreatitis （SAP） in multiple organ injury is a hotspot in the surgical field. In clinical practice, the main complicated organ dysfunctions are shock, respiratory failure, renal failure, encephalopathy, with the rate of hepatic diseases being closely next to them. The hepatic injury caused by SAP cannot only aggravate the state of pancreatitis, but also develop into hepatic failure and cause patient death, lts complicated pathogenic mechanism is an obstacle in clinical treatment. Among many pathogenic factors, the changes of vasoactive substances, participation of inflammatory mediators as well as OFR （oxygen free radical）, endotoxin, etc. may play important roles in its progression.

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.

Proteasome inhibitor ameliorates severe acute pancreatitis and associated lung injury of rats

AIM: To observe the effect of proteasome inhibitor MG-132 on severe acute pancreatitis (SAP) and associated lung injury of rats. METHODS: Male adult SD rats were randomly divided into SAP group, sham-operation group, and MG-132 treatment group. A model of SAP was established by injection of 5% sodium taurocholate into the biliary- pancreatic duct of rats. The MG-132 group was pretreated with 10 mg/kg MG-132 intraperitoneally (ip) 30 min before the induction of pancreatitis. The changes in serum amylase, myeloperoxidase (MPO) activity of pancreatic and pulmonary tissue were measured. The TNF-α level in pancreatic cytosolic fractions was assayed with an enzyme-linked immunosorbent assay (ELISA) kit. Meanwhile, the pathological changes in both pancreatic and pulmonary tissues were also observed. RESULTS: MG-132 significantly decreased serum amylase, pancreatic weight/body ratio, pancreatic TNF-α level, pancreatic and pulmonary MPO activity (P < 0.05). Histopathological examinations revealed that pancreatic and pulmonary samples from rats pretreated with MG-132 demonstrated milder edema, cellular damage, and inflammatory activity (P < 0.05). CONCLUSION: The proteasome inhibitor MG-132 shows a protective effect on severe acute pancreatitis and associated lung injury of rats.

Severe acute pancreatitis in the elderly: Etiology and clinical characteristics

AIM: To investigate the etiology and clinical characteristics of severe acute pancreatitis (SAP) in elderly patients (≥ 60 years of age). METHODS: We reviewed retrospectively all the SAP cases treated in Xuanwu Hospital in Beijing between 2000 and 2007. RESULTS: In 169 patients with SAP, 94 were elderly and 16 died. Biliary and idiopathic etiologies were the first two causes that accounted for over 90% of SAP in the elderly. Biliary, hyperlipemic and alcoholic etiologies were the first three causes in the young. The proportion of co- morbidity of cholelithiasis, biliary infection, hypertension and coronary heart disease in the aged was significantly higher than that in their young partners. The scores of APACHE Ⅱ and Ranson were also significantly higher in the elderly except the CT score. Organ failures were more common in the elderly, but the local pancreatic complications were not different between the two groups. Mortality of the aged was correlated with the severity of SAP, multiple co-morbidity and incidence of multiple organ dysfunction syndrome (MODS). MODS was the main cause of death. CONCLUSION: The etiology of SAP in the elderly is quite different from that in the young. Biliary and unknown factors are main causes in the aged. The elderly are subject to major organ failures but there is no difference in the occurrence of local pancreatic complications between the elderly and the young. It is crucial to monitor and improve the functions of major organs so as to prevent MODS in the aged with SAP.

Acute necrotizing pancreatitis complicated with pancreatic pseudoaneurysm of the superior mesenteric artery: A case report

Acute necrotizing pancreatitis complicated with pancreatic pseudoaneurysm is a rare emergency associated with high mortality that demands immediate treatment to save the patient’s life. We treated a 64-year-old man who presented with a bleeding pseudoaneurysm of the superior mesenteric artery caused by acute pancreatitis, using interventional embolizing therapy. In the present report we show that interventional treatment is an effective therapeutic modality for patients with acute necrotizing pancreatitis complicated with intra-abdominal bleeding.

Extra-pancreatic complications,especially hemodialysis predict mortality and length of stay,in ICU patients admitted with acute pancreatitis

Background and aims:Patients in the intensive care unit(ICU)with acute pancreatitis(AP)are at risk for extra-pancreatic complications given their severe illness and prolonged length of stay.We sought to determine the rate of extra-pancreatic complications and its effect on length of stay(LOS)and mortality in ICU patients with AP.Methods:We performed a retrospective cohort study of ICU patients admitted to a tertiary-care center with a diagnosis of AP.A total of 287 ICU patients had a discharge diagnosis of AP,of which 163 met inclusion criteria.We calculated incidence rates of extra-pancreatic complications and performed a univariate and multi-variable analysis to determine predictors of LOS and mortality.Results:There were a total of 158 extra-pancreatic complications(0.97 extra-pancreatic complications per patient).Ninetyfive patients had at least one extra-pancreatic complication,whereas 68 patients had no extra-pancreatic complications.Patients with extra-pancreatic complications had a significantly longer LOS(14.7 vs 8.8 days,p<0.01)when controlling for local pancreatic complications.Patients with non-infectious extra-pancreatic complications had a higher rate of mortality(24.0%vs 16.2%,p=0.04).Patients requiring dialysis was an independent predictor for LOS and mortality(incidence risk ratio[IRR]1.73,95%confidence interval[CI]:1.263–2.378 and IRR 1.50,95%CI 1.623–6.843,p<0.01)on multi-variable analysis.Coronary events were also a predictor for mortality(p=0.05).Other extra-pancreatic complications were not significant.Conclusions:Extra-pancreatic complications occur frequently in ICU patients with AP and impact LOS.Patients with noninfectious extra-pancreatic complications have a higher mortality rate.After controlling for local pancreatic complications,patients requiring dialysis remained an independent predictor for LOS and mortality.