Is the association of serum lipase with beta2-microglobulin or C-reactive protein useful for establishing the diagnosis and prognosis of patients with acute pancreatitis?

In the Emergency Department it is mandatory to establish the diagnosis and the prognosis of acute pancreatitis as soon as possible. To evaluate whether the association of serum lipase either with serum beta2-microglobulin or with C-reactive protein allows simultaneously to establish the diagnosis and the prognosis of acute pancreatitis, 96 patients with acute abdomen were studied. Fifty-eight patients had non-pancreatic acute abdomen and the remaining 38 had acute pancreatitis: 23 mild acute pancreatitis, and 15 severe acute pancreatitis. Forty healthy subjects were studied as controls. Lipase, beta2-microglobulin and C-reactive protein were determined in the serum of all subjects, using commercial kits. One patient with acute pancreatitis was not correctly classified when lipase was used to discriminate between patients with non-pancreatic acute abdomen and those with acute pancreatitis. For the discrimination of patients with severe acute pancreatitis from those with the mild form of the disease in the remaining 37 acute pancreatitis patients, beta2-microglobulin had a sensitivity of 53.3 %, specificity of 81.8%, and prognostic accuracy of 70.3 % (27 of the 37 patients correctly classified); 87.5 % of the 96 cases were correctly classified. C-reactive protein showed a lower prognostic accuracy than beta2-microglobulin: sensitivity 86.7%, specificity 45.5%, accuracy 62.2 %; 84.4 % of the cases were correctly classified. Using the polychotomous logistic regression analysis we found the same accuracy in discriminating between patients with acute pancreatitis and those with non-pancreatic acute abdomen (99.0%) but a lower accuracy (54.1%) between patients with severe acute pancreatitis and those with the mild form of the disease. Our study shows that the association of serum lipase with beta2-microglobulin or with C-reactive protein is not useful in simultaneously establishing the diagnosis and prognosis of acute pancreatitis.     

Mucinous cystadenoma of the pancreas as a cause of acute pancreatitis

Acute pancreatitis is only rarely the first presentation of a cystic neoplasm of the pancreas. Mucinous cystadenomas have not been reported to be a cause of acute pancreatitis; however, we present two cases of mucinous cystadenoma of the pancreas which have caused acute pancreatitis. Both patients (female) presented acute abdominal pain, with serum amylase elevation and ultrasound scan (US) and computed tomography (CT) evidence of moderate pancreatitis, which resolved with medical treatment; fluid collection in the distal pancreas had been misinterpreted as a pseudocyst. There was no history of alcohol abuse or gallstone disease. After distal pancreatectomy the diagnosis of mucinous cystadenoma was confirmed; in one case a large pseudocyst was associated with this diagnosis. Pre-operative differential diagnosis between inflammatory and neoplastic cysts is difficult, especially when the patient's first presentation is due to an episode of acute pancreatitis. A neoplastic cyst should be considered when acute pancreatitis attacks occur in non-alcoholic women, who do not have gallstone disease.     

Results and consequences of frequent quality control of quantitative clinical 1H-MR-spectroscopy

BACKGROUND: The cut-off point of serum C-reactive protein to differentiate the mild from the severe form of acute pancreatitis is still debated; data concerning the C-reactive protein pattern in assessing the severity of acute biliary pancreatitis are lacking. AIM: To define the best cut-off point in differentiating the severe from the mild form of acute biliary pancreatitis. PATIENTS: Fifty patients with acute biliary pancreatitis: 34 patients with mild pancreatitis and 16 with the severe form of the disease were studied. METHODS: Serum C-reactive protein concentrations were assessed in all patients upon admission and for the following 5 days. RESULTS: No significant difference in serum C-reactive protein levels was found in the first 2 days in patients with mild pancreatitis compared to those with the severe form of the disease. Using a cut-off point of 11 mg/dl, the sensitivity of serum C-reactive protein in assessing the severity of acute pancreatitis during the first two days of the study was 9% and 57%, the specificity, 93% and 81%, and the accuracy 71% and 74%, respectively. CONCLUSIONS: Serum determination of C-reactive protein in the first 48 hours of the disease is not a reliable marker of the severity of acute biliary pancreatitis.     

Clinical value of pancreatitis-associated protein in acute pancreatitis

OBJECTIVES: Pancreatitis-associated protein (PAP) is a secretory protein that is overexpressed by the pancreas during acute pancreatitis. This study was carried out to assess the clinical value of PAP in acute pancreatitis, particularly its ability to indicate the severity of the disease. METHODS: Twenty-one healthy subjects, 58 patients with acute pancreatitis, and 20 patients with nonpancreatic acute abdomen were studied. In addition to serum PAP concentration, serum concentrations of amylase, lipase, and C-reactive protein (CRP) were measured at admission and, in patients with acute pancreatitis, during the following 5 days. RESULTS: On admission, serum PAP concentrations were abnormally high in 46 of the 58 patients with acute pancreatitis (79%); serum amylase, in 57 patients (98%); serum lipase, in all patients (100%); and serum CRP, in 40 patients (69%). During the subsequent days of the study, PAP and CRP tended to increase, whereas amylase and lipase decreased. No significant differences in PAP or amylase and lipase concentrations were found between patients with mild pancreatitis and those with severe pancreatitis during the entire study period, whereas from the third day to the sixth day, CRP concentrations were significantly higher in patients with severe pancreatitis than in those with mild pancreatitis. Among the 20 patients with nonpancreatic acute abdomen, PAP concentrations were abnormally high in 10 (50%), whereas amylase concentrations were abnormally high in five (25%), and lipase concentrations were high in two (10%). CONCLUSIONS: Our results indicate that the clinical value of PAP in acute pancreatitis is quite limited and, in particular, that PAP is not a useful marker for determining the severity of the disease.     

Acute pancreatitis due to pyritinol: an immune-mediated phenomenon

A 23-year-old man experiencing three episodes of acute pancreatitis of undetermined etiology is described. Repeated questioning revealed that all three events had occurred after intake of the drug pyritinol. Controlled rechallenge with a single dose of the drug led to a fourth episode of acute pancreatitis. Skin testing was negative, but lymphocyte stimulation tests and double fluorescence analysis detected pyritinol-activated CD4 and CD8 lymphocytes. Together with the clinical observation that the intervals between drug intake and start of symptoms of acute pancreatitis became shorter with repeated exposure, the data are consistent with an immune-mediated origin of the pancreatitis. Pyritinol has to be added to the list of drugs capable of inducing acute pancreatitis.     

Seizure control after stimulation of the vagus nerve: clinical outcome measures

Our objective was to determine whether pleural effusion is a predictor of severity in acute pancreatitis and, if so, whether it is an independent predictor. One hundred ninety-six consecutive cases of acute pancreatitis from October 1, 1994, to September 30, 1995, were reviewed. Medical records were analyzed for evidence of pleural effusion by chest radiograph and severe acute pancreatitis by identification of pancreatic necrosis or organ system dysfunction. Data were analyzed to determine if identification of pleural effusion provided an early sign of severity. Among 135 patients who underwent chest radiography, pleural effusion was seen in 16 of 19 (84.2%) with severe pancreatitis and 10 of 116 (8.6%) of patients with mild pancreatitis (p < 0.001). Pleural effusion was noted in severe pancreatitis prior to clinical or computed tomography evidence of severity in only 20% of cases. Pleural effusion is strongly associated with severity in acute pancreatitis but provides independent information on severity in only a minority of cases.     

Acute pancreatitis: conservative therapy)

Conservative treatment of acute pancreatitis is symptomatic and depends on the severity of the disease. For treatment of mild pancreatitis, fasting and intravenous application of fluids and analgetics is usually sufficient. Patients with severe pancreatitis should be monitored in an Intensive Care Unit and may require antibiotics. For treatment of acute pancreatitis, a large number of interventions has been suggested. They include nasogastric tubes, drugs which reduce pancreatic and gastric secretion, and treatments which inhibit activated proteases. Controlled studies have shown that most of these measures are ineffective. The value of early ERCP in acute pancreatitis is still under debate. ERCP appears to be helpful in biliary pancreatitis, especially if choledocholithiasis is present. Surgery should be reserved to those patients who do not respond to conservative treatment.     

Amylase activity of parotid saliva in acute and chronic pancreatitis

The activity of the alpha-amylase was estimated in the parotid resting saliva of 17 subjects without evidence of pancreatic disease, 17 patients with chronic relapsing pancreatitis in the intervals between acute attacks, and also in 4 patients with acute pancreatitis and 3 patients with an acute attack of chronic relapsing pancreatitis. In the patients with chronic relapsing pancreatitis between attacks the concentration, output and specific activity of the salivary amylase were significantly lowered. The patients with acute pancreatitis exhibited salivary amylase concentrations in the uppper normal to grossly supranormal range, whereas those of the patients with acute attacks of chronic relapsing pancreatitis were distinctly reduced. Unlike the amylase output, the amylase concentration was independent of the rate of salivary flow. Simultaneous infusion of secretin and pancreozymin produced a significant increase in the parotid salivary amylase levels in both the patients without pancreatic disease and in those with chronic relapsing pancreatitis between acute attacks.     

Chronic pancreatitis, acute pancreatitis

MRCP has been recognized as a safe and noninvasive diagnostic method. In the present study we evaluated the usefulness of MRCP in diagnosis of chronic and acute pancreatitis. Two-dimensional fast asymmetric spin-echo (FASE) MRCP was performed in 40 patients with chronic pancreatitis and 13 with acute pancreatitis. In 29 patients (72.5%) with chronic pancreatitis and 9 (66.7%) with acute pancreatitis, main pancreatic duct (MPD) was visualized entirely. MRCP could demonstrate the characteristic findings of chronic pancreatitis such as dilatation and irregularity of MPD in most cases. In acute pancreatitis, MRCP indicated that MPD was normal in diameter, but irregular in configuration compared with that of the control group. MRCP may facilitate the diagnosis of chronic and acute pancreatitis.     

Laparoscopy for the impalpable testes. Initial experience of one center

Endoscopic treatment of acute pancreatitis has been proposed in different conditions: acute biliary pancreatitis, pancreatitis related to pancreas divisum or in case of pseudocysts. The efficacy of such endoscopic procedure is discussed.     

Evaluation of the clinical usefulness of APACHE II and SAPS systems in the initial prognostic classification of acute pancreatitis: a multicenter study

The clinical usefulness of the APACHE II and SAPS systems in the early prognostic classification of patients with acute pancreatitis has been evaluated in a prospective multicenter study. We aimed to identify early those patients with acute pancreatitis who should be monitored closely to expedite the detection and treatment of complications. One hundred eighty-two patients with acute pancreatitis were included; 28 were classified as severe, having developed at least one major complication of the disease. The scores obtained through the APACHE II and SAPS systems in these severe cases were significantly higher than the scores in the mild cases of acute pancreatitis (p < 0.001). The sensitivity of these systems in the prognostic classification of acute pancreatitis was 70.4% for APACHE II and 66.7% for SAPS, and the specificity was 79.1% for both. When applying APACHE II and SAPS systems in the early phase of acute pancreatitis, the possibility of misdiagnosing the severity exists, thus limiting the application of these systems in the initial assessment of prognostic classification. In conclusion, APACHE II and SAPS systems are of limited clinical utility in the early prognostic evaluation of acute pancreatitis because of their low positive predictive value.     

Postoperative changes in the coagulation and fibrinolytic systems in endoluminal stent-graft treatment of thoracic aortic aneurysms

Length of stay (LOS) predictions in acute pancreatitis could be used to stratify patients with severe acute pancreatitis, make treatment and resource allocation decisions, and for quality assurance. Artificial neural networks have been used to predict LOS in other conditions but not acute pancreatitis. The hypothesis of this study was that a neural network could predict LOS in patients with acute pancreatitis. The medical records of 195 patients admitted with acute pancreatitis were reviewed. A backpropagation neural network was developed to predict LOS >7 days. The network was trained on 156 randomly selected cases and tested on the remaining 39 cases. The neural network had the highest sensitivity (75%) for predicting LOS >7 days. Ranson criteria had the highest specificity (94%) for making this prediction. All methods incorrectly predicted LOS in two patients with severe acute pancreatitis who died early in their hospital course. An artificial neural network can predict LOS >7 days. The network and traditional prognostic indices were least accurate for predicting LOS in patients with severe acute pancreatitis who died early in their hospital course. The neural network has the advantage of making this prediction using admission data.     

Cell sensitivity to Fas-mediated apoptosis depends on three forms of Fas-antigen]

Bowel rest during treatment of acute pancreatitis deprives the gut of nutrients and affects its structure and function. Enteral feeding is usually performed late in the course of acute pancreatitis and therefore cannot prevent intestinal barrier dysfunction and possible bacterial translocation. To assess the effect of early enteral nutrition we performed a prospective study on 21 patients (11 males/10 females) presenting with severe acute pancreatitis (13 biliary, 6 alcoholic, and 2 miscellaneous). Severity was established by a mean Ranson score of 3.57. All but one patient could be fed through a double-lumen nasogastrojejunal tube within 60 h after admission. No significant complication of the technique was observed. We conclude that early jejunal feeding can be used safely in severe acute pancreatitis. Further comparative studies are necessary to demonstrate any superiority to total parenteral nutrition.     

Mutation analysis of the 6-pyruvoyl-tetrahydropterin synthase gene in Chinese hyperphenylalaninemia caused by tetrahydrobiopterin synthesis deficiency

BACKGROUND: The systemic manifestations of acute pancreatitis are responsible for the majority of pancreatitis-associated morbidity and mortality and are now believed to be due to the actions of specific inflammatory cytokines. This report summarizes what is known about the role of cytokines in the pathogenesis of acute pancreatitis. METHODS: Comprehensive literature review of experimental pancreatitis as well as all reports of cytokine involvement during clinical pancreatitis. RESULTS: Several cytokines and other noncytokine inflammatory mediators are produced rapidly during pancreatitis. These mediators arise in many tissues in a predictable fashion independent of the animal model used or the underlying etiology in human disease. Preventing the activities of these mediators has a profound beneficial effect in experimental animals. CONCLUSIONS: A few recently described inflammatory mediators are believed to be primarily responsible for the systemic manifestations of acute pancreatitis and its associated distant organ dysfunction. The predictable nature in which they are produced may allow for novel approaches to treating this disease. Am J Surg.     

Acute phase proteins in acute pancreatitis

INTRODUCTION: Most attacks of acute pancreatitis are self-limiting, but in 10-20% of cases, however, severe diseases with systemic complications develop. During the last few years, it has been recognized that acute phase proteins have an important role in the pathophysiology of acute pancreatitis. The present study examines the value of C-reactive protein, alpha-1-antitrypsin and orosomucoid in the assessment of severity of acute pancreatitis. MATERIAL AND METHODS: 150 adult patients suffering from acute pancreatitis by Mayer's clinical criteria (10) were divided in two groups. The first one (n = 50) consisted of patients with severe form of the disease and the second (n = 100) of patients with a mild form of acute pancreatitis. Acute phase proteins (C-reactive protein, alpha-lantitrypsin and orosomucoid) were determined quantitatively in both groups on the 1, 2, 3, 7 and 14th day of the disease onset. RESULTS: Increase in C-reactive protein values was observed in both groups. There was statistically significant greater increase in C-reactive protein in patients with severe acute pancreatitis than in those with mild form of the disease. C-reactive protein values fell slowly in all patients. Serum alpha-1 antitrypsin values were less increased than C-reactive protein values. There was a greater increase in patients with severe form of disease. The increase of orosomucoid was seen only after the third day of the disease onset and there was not a significant difference in values between the two groups. DISCUSSION: One of the most important problems in treating patients with acute pancreatitis is to detect patients with a severe form of the disease as early as possible, so that adequate treatment can be started immediately. The severity of acute pancreatitis is graded by Ranson and Imrie scores, but they request 48 hours for prognosis to be defined. Despite intensive research, no single laboratory test or pathophysiologic parameters have been found to accomplish early diagnosis. Recent studies suggest that single biologic markers such as acute phase proteins may soon allow a simple and early assessment of the prognosis. CONCLUSION: This study suggests that a C-reactive protein is a good early marker for the severity of acute pancreatitis. The high increased levels at the beginning point to serious course of disease in future. The increase of alpha-1-antitrypsin is of a similar importance, while the increased orosomucoid, appearing only after the third day, is of no importance in relation to the prognosis of the disease.     

Autoimmune pancreatitis: radiologic findings in three histologically proven cases

We describe the radiologic findings of autoimmune pancreatitis, a rare variant of pancreatitis. The radiologic findings of autoimmune pancreatitis are pathognomonic and very different from those of ordinary types of acute or chronic pancreatitis. This condition is a new clinical entity that is effectively treated with steroid therapy. It is important to recognize the radiologic characteristics of autoimmune pancreatitis to avoid surgical resection and start steroid therapy.     

Acute pancreatitis associated with the use of lisinopril

OBJECTIVE: To report a case of acute pancreatitis associated with lisinopril use. CASE SUMMARY: A 67-year-old man with no past history of pancreatitis or its associated risk factors developed acute pancreatitis after taking lisinopril for two years. To date, the use of angiotensin-converting enzyme (ACE) inhibitors and development of pancreatitis has been described in the literature with captopril, enalapril maleate, and one case temporally related to lisinopril use. CONCLUSIONS: The use of ACE inhibitors as first-line agents in controlling hypertension and congestive heart failure has increased. In addition to monitoring for efficacy and commonly reported adverse effects, clinicians need to be aware that acute pancreatitis may occur with all ACE inhibitors.     

Phenformin-associated pancreatitis

Although phenformin has been previously reported to be associated with acute pancreatitis, little emphasis of this association has been made in the literature. We report the case of a 70-year-old diabetic man who developed acute hemorrhagic pancreatitis and severe lactic acidosis while taking phenformin. The patient was not taking any other medications, nor did he have any of the known metabolic conditions associated with pancreatitis. We review the four previously published cases of patients who developed acute pancreatitis while taking phenformin. Three of those patients also developed lactic acidosis, a well-known complication of phenformin therapy. Although phenformin has been reported to increase the serum amylase activity and to alter the content of the pancreatic secretions in response to various stimuli, the manner in which the drug might cause acute pancreatitis remains completely unknown.     

Pancreatic colon stenoses

Benign colonic stenosis may be caused by pancreatitis. Colonic obstruction arising during the acute stage of pancreatitis is mostly found to be reversible. Persistant colonic stenosis after acute or relapsing pancreatitis may point to an adjacent abscess. Two patients with pancreatitic colonic stenosis illustrate those different courses of the disease.