Personalized approach in optimizing the treatment of acute pancreatitis

In order to determine the effectiveness of the use of remaxol based on a personalized approach in patients with acute pancreatitis, based on the establishment of gene polymorphism of integrin beta-3 (T1565C, ITGB3), integrin alpha-2 (C807T, ITGA2), fibrinogen (G(-455)A, FGB) and plasminogen activator inhibitor (5G(-675)4G, SERPINE1), a study of 84 patients with acute pancreatitis of varying severity was conducted. As a result of the study, it was proved that in order to increase the effectiveness of treatment of patients with severe acute pancreatitis upon admission, in addition to clinical, laboratory and instrumental studies, it is necessary to conduct genetic testing of the genotypes of the polymorphism of the GPIIa gene (T1565C), ITGA2 (C807T), FGB (G(-455)A) and SERPINE1 (5G(-675)4G) to develop a personalized approach in the treatment of this severe category of patients. Key words: acute pancreatitis, genotype, DNA diagnostics, genetic testing of genotypes, personalized medicine.

Assessment of BISAP Scoring System and C-Reactive Protein Analysis in Predicting Severity of Acute Pancreatitis

BACKGROUND Acute pancreatitis (AP) is a dormant deadly illness. The range of seriousness of the ailment goes from mellow self-restricting disease to an exceptionally lethal severe necrotizing pancreatitis. The disease has such a variable course that it may manifest as a simple pain in the abdomen to severe haemorrhagic pancreatitis with septicaemic shock, multi-organ dysfunction syndrome and ultimately leading to death. A cost-effective better prognosticative index is needed for the assessment of the severity of AP. Here in this study, we wanted to assess the role of BISAP scoring systems and CRP for analysis and comparing their values to determine the severity of AP and the prognosis of the disease. METHODS A prospective observational study was done on 83 patients diagnosed with AP after fulfilment of inclusion criteria. Patients were subjected to severity index, bedside index for severity in acute pancreatitis (BISAP) score and CRP calculation and statistical analysis was done with SPSS software. RESULTS In our study, AP was more prevalent in males 87.95 % than females 12.05 %. AP was found to be more common in cases ≤ 40 years of age, however, the mean age of presentation was 38.14 ± 12.59 years. We calculated the sensitivity and specificity of the BISAP score and C-reactive protein (CRP) by co-relating it with CT severity index as gold standard according to which the sensitivity was found to be 64 % and specificity was found to be 85 % for BISAP. The sensitivity and specificity of CRP was 64 % and 85 % respectively. CONCLUSIONS BISAP is an easy way to anticipate the severity of AP within 24 hours. It also helps to prognosticate AP. CRP can also be used to aid BISAP in the assessment of severe acute pancreatitis (SAP). KEY WORDS Acute Pancreatitis, BISAP, CRP.

Study of BISAP Scoring System, Ranson’s Scoring System and C-Reactive Protein Level as Predictors of Clinical Outcome in Acute Pancreatitis

BACKGROUND This study was conducted to compare BISAP scoring system, Ranson’s score and CRP levels in predicting the clinical outcome in acute pancreatitis and for early detection of severity and organ failure in acute pancreatitis. METHODS This study was an observational longitudinal analytical study conducted among patients admitted with diagnosis of acute pancreatitis, in Father Muller Medical College Hospital, Mangalore, from November 2016 to March 2018. The study was started after obtaining ethical clearance from the institution’s ethical clearance committee. All patients diagnosed with acute pancreatitis between the age 20 and 60 years were included in the study. RESULTS Comparison of serum CRP levels between the Atlanta classified groups shows that severe group has the maximum value of 340.966 and mild has the minimum value of 55.38. This difference is statistically significant with a test value of 16.543 and a P value of < 0.001. On comparison of the test group, Ranson’s score with the BISAP score, the test group had a sensitivity of 89.3 % and specificity of 77.3 %. CONCLUSIONS The study has demonstrated the concordance between Ranson’s score, BISAP score and serum CRP level as predictors of clinical outcome in acute pancreatitis. KEY WORDS Acute Pancreatitis, Clinical Outcome, C Reactive Protein, Scoring Systems.

PROCALCITONIN IN EARLY PREDICTION OF ACUTE SEVERE PANCREATITIS

The aim of the study was to analyze the prognostic potential of procalcitonin in acute pancreatitis complicated by ascites-peritonitis. Materials and methods: The study analyzed the results of a comprehensive examination and treatment of 18 patients with acute pancreatitis complicated by enzymatic ascites-peritonitis, including 13 patients who were treated in the surgical department of KP “Poltava Regional Clinical Hospital. MV Sklifosovsky POR “, and 5 patients of other emergency hospitals in Poltava, in the period from 2017 to 2019. In addition to standard screening methods, these patients were additionally tested for procalcitonin to predict an adverse course in the early period. Results: To assess the relationship between the presence of elevated procalcitonin levels at the time of hospitalization of 0.5 ng / ml and above and unsatisfactory treatment results, differences were assessed using an accurate Fisher test. When comparing differences in the development of infectious complications in the dynamics of the disease in patients of the study group depending on the presence of elevated concentrations of procalcitonin or its absence at the time of hospitalization, a significant difference was found (p <0.05). Conclusions: In our opinion, the use of procalcitonin as a predictor of infectious complications in the dynamics of the disease will determine the category of patients in whom reducing the risk of flora translocation through the use of early oral antibiotic prophylaxis and parenteral drugs tropic to pancreatic tissue may reduce the incidence of purulent complications. In another category of patients, antibacterial therapy is not advisable due to the low risk of purulent-septic complications. KEY WORDS: acute pancreatitis, procalcitonin, ascites-peritonitis, severity of the condition

Features of the course of acute pancreatitis in patients with obesity

The purpose of the study is to investigate the course of acute pancreatitis in obese patients, the development of local and systemic complications and mortality rates. Materials and methods We have taken and analyzed 482 histories of acute pancreatitis, who has been treatmented at Kyiv Regional Clinical Hospital from January 1, 2011 to February 2, 2019. The data were statistically processed in the Exel 2010 program using a descriptive method using relative , absolute numbers, mean square deviations and their errors. A correlation relationship between variables was studied using the Pearson criterion (R2). Testing the significance of the difference between the two independent groups was carried out with the help of the t-criterion of the Student. Results In our study we had 482 patients, 260 patients (54%) had obesity (the study group), for comparison, a control group of patients with normal body weight was chosen, the total number of which was 222 (46%) patients. Obesity patients had a higher average age (55.4 ± 9.4 years, p = 0.01), also they had statistically greater percentage of severe cases of acute pancreatitis (85 (32.7%) vs 16 (7.2%); p = 0.01 *). We note the increase in the percentage of the course of severe pancreatitis in patients with weight gain from 10.20% to 53.93% (p = 0.03) *. Obesity patients had the longer bed-days in the hospital than in patients with normal body weight. In addition, they observed an increase of twice the bed in the reanimation and intensive care unit (5.8 ± 0.8 vs 2.7 ± 0.5 days, p = 0.01 *). When investigating the mortality rate, it should be noted that the main cause of death was the progression of organ failure of 30 (6.3%), pulmonary embolism (TB) - 15 (3.1%) and DIC 18 (3.7%) . Conclusions. The presence of obesity in patients involves a high risk of severe acute pancreatitis, this risk increases with an increase in the body mass index. In addition, in obese patients we have a higher bed-day in-patient and in-patient-care settings, which increases the total cost of treatment and requires a cost-effective algorithm in the future. A high mortality rate in obese patients requires improved treatment algorithm. Key words: acute pancreatitis, obesity.

Pancreatitis in the Critical Care Setting

Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016. Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

Pancreatitis

Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016. Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

Ūminio nekrozinio pankreatito gydymo patirtis

Audrius Šileikis, Virgilijus Beiša, Blažiejus Jucevičius, Saulius Jurevičius, Albinas Lamošiūnas, Kęstutis StrupasVilniaus universiteto ligoninės Santariškių klinikų Pilvo chirurgijos centras,Santariškių g. 2, LT-08661 VilniusEl paštas: [email protected] Įvadas / tikslas Ūminis pankreatitas – tai liga, pasižyminti sunkiai prognozuojama klinikine eiga ir dideliu mirštamumu. Šio straipsnio tikslas – pateikti mūsų sukauptą gydymo patirtį ir ją palyginti su literatūros duomenimis. Ligoniai ir metodai Retrospektyviuoju metodu išnagrinėta 126 ligonių, 2002–2005 m. gydytų nuo nekrozinio pankreatito, medicininė dokumentacija. Ūminis pankreatitas buvo diagnozuojamas remiantis klinika, instrumentiniais tyrimais ir amilazės kiekio padidėjimu kraujyje. Sunkumo laipsniui nustatyti naudotasi Atlantos klinikine klasifikacija. Kasos nekrozei patvirtinti būdavo atliekama kasos KT su intraveniniu kontrastavimu. Ligoniai operuoti tais atvejais, kai būdavo įrodyta kasos nekrozinio audinio infekcija, atsirasdavo intraabdominalinė komplikacija arba toliau gydomo konservatyviai ilgiau nei tris savaites ligonio būklė negerėdavo. Operuojant ligonius būdavo atliekamos nekrektomijos, paskui taikytas atviras ar uždaras plovimo būdas. Rezultatai Pagrindinė ūminio pankreatito priežastis – alkoholis (48%). Daugumai gydytų ligonių kasos nekrozė neviršijo 30% kasos dydžio (69%). Dauguma ligonių išoperuota (57,14%). Pagrindinė indikacija operuoti – kasos nekrozinių audinių infekcija (51,4%). Lyginant kasos nekrozės infekcijos dažnį su kasos nekrozės dydžiu nustatyta, kad kuo didesnis nekrozės plotas, tuo dažnesnė infekcija. Palyginus operacijų būdus konstatuota, kad ligoniams po nekrektomijos ir vėliau taikyto uždaro plovimo žarninių fistulių buvo mažiau ir trumpesnė pooperacinio gydymo trukmė. Mirė 15 ligonių (12%), iš jų 7 ligoniai – pirmosios klinikinės fazės metu ir 8 ligoniai – antrosios. Išvados Norint išvengti sunkaus ūminio pankreatito sukeliamų komplikacijų, dėl kurių gali ištikti mirtis, būtina laiku diagnozuoti ir tinkamai gydyti ligą. Nustatant ūminio pankreatito sunkumo laipsnį, būtina vadovautis Atlantos klinikiniais kriterijais. Diagnozavus kasos nekrozę, rekomenduojama infekcijos profilaktikai skirti antibiotikų. Optimalus operacinio gydymo laikas – trečia ar ketvirta savaitė nuo ligos pradžios. Pageidautina, kad ligoniai, sergantys sunkiu ūminiu pankreatitu, būtų gydomi tretinio lygio centruose, kuriuose būtų užtikrinta jų stebėsena ir adekvati komplikacijų korekcija. Reikšminiai žodžiai: ūminis pankreatitas, kasos nekrozė, infekcija, chirurginis gydymas Experience in treating acute necrotic pancreatitis Audrius Šileikis, Virgilijus Beiša, Blažiejus Jucevičius, Saulius Jurevičius, Albinas Lamošiūnas, Kęstutis StrupasCenter of Abdominal Surgery, Vilnius University Hospital "Santariškių klinikos",Santariškių str. 2, LT-08661 Vilnius, LithuaniaE-mail: [email protected] Background / objective Acute pancreatitis is a disease which is notable for its complicated forecast of the clinical course and for its high degree of mortality. Thus, the goal of the present article is to reveal the accumulated experience in its treatment and to compare it with the data presented in the literature. Patients and methods The medical documentation of 126 patients who underwent treatment against necrotics pancreatitis within the years 2002–2005 have been investigated by the retrospective method. Acute pancreatitis was diagnosed referring to the clinic, instrumental investigation and an increase of the quantity of amylase in the blood. The Atlanta clinical classification was applied seeking to ascertain the degree of severity. CT of the pancreas together with intravenous contrasting was employed to prove pancreatic necrosis. The patients were operated on, if infection of pancreatic necrosis was proved, if the intra-abdominal complication occurred or if the patient’s condition did not improve while continuing the conservative treatment for longer than three weeks. Debridment was done while operating on the patients; afterwards the open and closed packing was carried out. Results Alcohol is the main cause of acute pancreatitis (48%). Pancreatic necrosis in most of the patients that had undergone treatment (69%) did not exceed 30% of the size of the pancreas. Most of the patients were operated on (57.14%). Infection of pancreatic necrosis served as the main indication for the operation (51.4%). The frequency of infection of pancreatic necrosis directly depended on the size of the necrosis. As regards the methods of operation, it was ascertained that there were less intestinal fistulas and duration of the post-operational treatment was shorter among the patients who had undergone the debridment followed by closed packing. Fifteen patients died (12%), of them seven died in the course of the first clinical phase and eight patients in the second phase. Conclusions To avoid the complications caused by serious acute pancreatitis, which may be mortal, the timely diagnostics and the proper tactics of treatment are obligatory. While ascertaining the degree of severity of acute pancreatitis it is necessary to refer to the criteria adapted by the Atlanta Congress. Upon diagnosing pancreatic necrosis, it is advisable to prescribe antibiotics to prevent infection. The most optimal time for operational treatment is the 3rd or the 4th week after the onset of the disease. Patients ill with severe acute pancreatitis should be treated in the high-level centers in which their monitoring and an adequate correction of the complications will be assured. Key words: acute pancreatitis, pancreatic necrosis, infection, antibiotic prophylaxis

Ūminio pankreatito etiopatogenezė

Audrius ŠileikisVilniaus universiteto ligoninės Santariškių klinikųPilvo chirurgijos centras,Santariškių g. 2, LT-08661 VilniusEl paštas: [email protected] Ūminis pankreatitas – tai liga, kurios metu pažeidžiama ne tik kasa, bet ir kiti organai, o sutrikus jų veiklai žmogus gali mirti. Todėl žinant ligos priežastis ir jos raidos mechanizmą galima išvengti mirtinų komplikacijų. Per pastaruosius du dešimtmečius atlikta nemažai mokslinių tyrinėjimų, leidusių geriau pažinti procesus, vykstančius sergant ūminiu pankreatitu. Jie ir pateikti šiame straipsnyje. Reikšminiai žodžiai: ūminis pankreatitas, citokinai Etiopathogenesis of acute pancreatitis Audrius ŠileikisCenter of Abdominal Surgery,Vilnius University Hospital "Santariškių klinikos",Vilnius, Santariškių str. 2, LT-08661 Vilnius, LithuaniaE-mail: [email protected] Acute pancreatitis is a disease which damages not only the pancreas, but also the other organs, through the functional derangement of which a person may die. Thus, the knowledge of the causes of the disease and the mechanism of the development of the illness itself may help to avoid the threatening inevitable complications. A number of scientific investigations, which contributed to understanding the processes going on in the course of acute pancreatitis have been carried out within the recent twenty years; they are discussed in the paper. Key words: acute pancreatitis, cytokine