Bacterial overgrowth syndrome of upper parts of gastrointestinal tract in acute necrotizing pancreatitis

Aim: to study the changes in the microflora of the upper part of digestive tract during acute necrotizing pancreatitis. Material and methods. Acute necrotizing pancreatitis was induced in 42 white rats; changes in the mucous microflora of the upper part of digestive tract were studied. Bacteriological examination of the contents of the proximal small intestine was performed in 42 patients with acute necrotic pancreatitis during gastrofibroscopy. Results and discussion. Induction of acute necrotic pancreatitis was accompanied by impaired colonization resistance of the intestinal mucosa due to the elimination of bifidobacteria and lactobacilli: the frequency of their growth from the mucosa decreased threefold (p<0.01), and the population level, respectively, by 25% (p<0.05) and by 36% (p<0.02). The mucosa was actively colonized by gram-negative pathogenic and conditionally pathogenic enterobacteria at high population level (3.07‒5.39 lg CFU/g), which allowed this microflora to overcome the damaged intestinal barrier and translocate. Pathogenic Escherichia spp. and Proteus spp. were cultivated from the mesenteric lymph nodes in 24 hours; Enterobacteria spp. and Staphylococci spp. were isolated from portal blood, pancreatic tissue, and peritoneal cavity 48 hours after induction of acute pancreatitis. Eight strains of gram-negative microorganisms were identified in small intestine in 69% of patients before surgery. Similar microflora was cultivated from pathological foci in 57.4% of patients after surgery. Conclusion. Severe deficiency of autochthonous anaerobic microflora occurred in the upper parts of the digestive tract in acute necrotizing pancreatitis, causing excessive colonization by pathogenic and conditionally pathogenic microorganisms and promoting bacterial translocation.

CYTOKINE REGULATION OF THE IMMUNE RESPONSE IN PATIENTS WITH ACUTE NECROTIC PANCREATITIS COMPLICATED BY MULTI-ORGANIC FAILURE

Aim: To study the cytokine regulation of the immune response in patients with acute necrotic pancreatitis (ANP) complicated by multiple organ failure (MON). Material and methods: A prospective cohort study of 22 patients with ANP complicated by MON who were treated in the clinic during 2014-2020 has been performed. We studied changes in blood cells expressing clusters CDIIa +, CD162 +, CD95 +, CD16 +, HLA-DR + molecules, levels of interleukins IL-2, IL-4, IL-6. The efficacy of treatment was determined by the duration of the organ failure, the level of postoperative complications and mortality. Results: Low expression of CD11a + and CD162 + on immunocompetent cells together with two time reduction of the content of CD95 + cells was observed in patients with ANP complicated by MON, which caused a decrease in the concentration of IL-6 at the same time with a slight increase in IL-4. A permanent reduction of the content of CD11a+-, CD162+- and CD95+-leukocytes simultaneously with a drop of the concentration of IL-4 and an excessive increase in the levels of IL-2 and IL-6 was associated with a negative course of the disease. Conclusions: The imbalance of cytokine regulation of the immune response develops in patients with ANP, complicated by MON. Progressive and excessive increase of plasma concentrations of IL-2 and IL-6 occurs as well as complete absence of IL-4 occurs in patients with an adverse course of the disease.

Role of Computed Tomography in Predicting Severity of Acute Pancreatitis

The current study was based on Computed Tomography (CT) findings and results. We found 63% of patients with acute interstitial edematous pancreatitis, and we found 37% of patients with acute necrotic pancreatitis in 46 cases. Based on our findings, we observed bulky pancreas among 26 cases (56.52%), 17 cases (36.95%) of pancreatic necrosis, 9 cases of pancreatic atrophy, 11 cases of pseudocyst, and 9 cases of peri-pancreatic fluid. When we evaluated the Modified CT Severity index among the study cases, we observed that 19.56% cases have mild index, the majority (56.52% cases) have moderate index while 23.91% have severe index. We also found that majority of the cases were clinically cured and discharged, i.e., 47.82%. 19.56% of the total study subjects reported recurrence of episodes of pancreatitis, while 30.43% of the total patients turned into chronic pancreatitis. This study presents a cross-sectional hospital-based analytical study carried out among 46 cases of AP referred to under the radiology department for further diagnostic evaluation, in a tertiary healthcare facility in Maharashtra. The present study Data Source included all the AP patients referred to the radiological department in a tertiary health research center. They met the standards for inclusiveness, which assented to the analysis. Type of study is Hospital analytical based study. The study duration is 18 months. Data collection was done through semi-structured, pre-designed, and pre-validated proformas in patients meeting inclusion requirements that included disease history, clinical outcomes, investigative records, and descriptions of surgical interventions.

Methods of extracorporeal detoxification in the treatment of patients with acute necrotic pancreatitis and DIC

The article analyzes the results of treatment of patients with acute necrotic pancreatitis and DIC who underwent extracorporeal detoxification (ECD) with heparin anticoagulation. We performed a retrospective analysis of the medical records of such patients who were treated in Moscow Clinical Hospital No. 24 in 2016–2017. Disorders indicating the development of DIC were detected in 38 patients with acute necrotic pancreatitis, 13 of them underwent extracorporeal detoxification methods, in 25 patients ECD was not used. The effect of ECD on hemostasis and clinical outcomes was studied. A tendency towards the progression of coagulopathy and an increase in the risks of developing hemorrhagic syndrome, multiple organ failure and death during extracorporeal detoxification with heparin anticoagulation was revealed. The insufficiently large number of patients included in the study does not allow us to draw a final conclusion about the use of heparin anticoagulation ECD in patients with acute destructive pancreatitis who were initially showing the signs of consumption coagulopathy, but the data obtained cast a doubt on its feasibility. Further research is needed to make recommendations for the use of ECD in this category of patients.

Long-term result of minimally invasive treatment of necrotic pancreatitis complicated by subtotal retroperitoneal phlegmon and unformed duodenal fistula

The authors present the case report of the patient with acute pancreatitis, multiple organ failure, anuria, pancreatogenic shock complicated by infection, diffused retroperitoneal phlegmon, unformed duodenal fistula, postnecrotic insular diabetes. Percutaneous catheter drainage of retroperitoneal abscess was performed under ultrasonic guidance. Therapy included somatuline. Irrigation-evacuation original system was used for debridement.

C-reactive protein and procalcitonin - laboratory markers of degrees of severity and complications of an acute necrotic pancreatitis

Objective. To conduct comparative estimation of efficacy of C-reactive protein and procalcitonin as laboratory markers for stratification of the patients severity state suffering an acute necrotic pancreatitis. Materials and methods. Prospective cohort investigation, including 151 patients with an acute necrotic pancreatitis, was conducted. Clinical, laboratory and bacteriological investigations were accomplished. The levels of C-reactive protein and procalcitonin were determined in the blood plasm. Results. The necrotic accumulations infectioning was diagnosed in 89 (58.9%) patients: local purulent complications - in 27, sepsis - in 33,septic shock - in 29. In 62 patients with sterile pancreonecrosis a C-reactive protein concentration have raised from (5.6 ± 0.89) to (206 ± 29) mg/l (p˂0.001). Development of purulent-septic complications was accompanied by significant and trustworthy (p<0.01) elevation of procalcitonin concentration: in the patients with sepsis - up to (5.05 ± 0.92) ng/ml, in the patients with septic shock - up to (7.25 ± 2.15) ng/ml. Conclusion. Simultaneous measurement of levels of C-reactive protein and procalcitonin in the blood plasm in patients, suffering acute necrotic pancreatitis, gives permission to determine the inflammatory process character and stratify the disease severity in its early terms.

EARLY CLINICAL MARKERS OF SEVERITY OF ACUTE NECROTIC PANCREATITIS

Summary. Acute necrotic pancreatitis carries enough difficulty in diagnosis and treatment. Destructive forms with retroperitoneal tissue damage cause lethality up to 70 %. The aim was to establish early clinical markers of disease severity. Material and methods. The results of surgical treatment of 120 patients with acute pancreatitis were analyzed. Patients were divided into groups: first group – 40 patients without parapancreatitis; second group — 80 patients with parapancreatitis. Peripheral blood reaction, main biochemical indicators, blood electrolytes, general condition by integral scales were evaluated in this groups. Results and discussion. On the admission day, the levels of erythrocytes and hemoglobin in patients in both groups were within normal limits. All patients had leukocytosis. All subjects had high LII rates. In the dynamics of treatment leukocytosis significantly decreased in the second group. Changes in clinical blood tests, urinalysis, ALT, AST, bilirubin, urea, creatinine were not significant. Conclusions. Postoperative mortality was 27.2 %. 67 % of patients had parapancreatitis. It was revealed, that reliable early markers of severity of acute necrotizing pancreatitis are: level of WBC, leucocyte intoxication index, intoxication indicator, organism`s resistance index, reactive neutrophilic response, C-reactive protein and level of calcium. It was proved, that evaluation of patient`s condition by scales ASSES, SAPS II and Ranson objectively reflects the patient`s condition during the course of treatment.