Increased number of non-degranulated mast cells in pancreatic ductal adenocarcinoma but not in acute pancreatitis.

Increasing evidence indicates that tumor microenvironment (TME) is crucial in tumor survival and metastases. Inflammatory cells accumulate around tumors and strangely appear to be permissive to their growth. One key stroma cell is the mast cell (MC), which can secrete numerous pro- and antitumor molecules. We investigated the presence and degranulation state of MC in pancreatic ductal adenocarcinoma (PDAC) as compared to acute ancreatitis (AP). Three different detection methods: (a) toluidine blue staining, as well as immunohistochemistry for (b) tryptase and (c) c-kit, were utilized to assess the number and extent of degranulation of MC in PDAC tissue (n=7), uninvolved pancreatic tissue derived from tumor-free margins (n=7) and tissue form AP (n=4). The number of MC detected with all three methods was significantly increased in PDAC, as compared to normal pancreatic tissue derived from tumor-free margins (p<0.05). The highest number of MC was identified by c-kit, 22.2∓7.5 per high power field (HPF) in PDAC vs 9.7∓5.1 per HPF in normal tissue. Contrary to MC in AP, where most of the detected MC were found degranulated, MC in PDAC appeared intact. In conclusion, MC are increased in number, but not degranulated in PDAC, suggesting that they may contribute to cancer growth by permitting selective release of pro-tumorogenic molecules.

Retrocrural space involvement on computed tomography as a predictor of mortality and disease severity in acute pancreatitis

BACKGROUND Because computed tomography (CT) has advantages for visualizing the manifestation of necrosis and local complications, a series of scoring systems based on CT manifestations have been developed for assessing the clinical outcomes of acute pancreatitis (AP), including the CT severity index (CTSI), modified CTSI, etc. Despite the internationally accepted CTSI having been successfully used to predict the overall mortality and disease severity of AP, recent literature has revealed the limitations of the CTSI. Using the Delphi method, we establish a new scoring system based on retrocrural space involvement (RCSI), and compared its effectiveness at evaluating the mortality and severity of AP with that of the CTSI. METHODS We reviewed CT images of 257 patients with AP taken within 3-5 days of admission in 2012. The RCSI scoring system, which includes assessment of infectious conditions involving the retrocrural space and the adjacent pleural cavity, was established using the Delphi method. Two radiologists independently assessed the RCSI and CTSI scores. The predictive points of the RCSI and CTSI scoring systems in evaluating the mortality and severity of AP were estimated using receiver operating characteristic (ROC) curves. PRINCIPAL FINDINGS The RCSI score can accurately predict the mortality and disease severity. The area under the ROC curve for the RCSI versus CTSI score was 0.962±0.011 versus 0.900±0.021 for predicting the mortality, and 0.888±0.025 versus 0.904±0.020 for predicting the severity of AP. Applying ROC analysis to our data showed that a RCSI score of 4 was the best cutoff value, above which mortality could be identified. CONCLUSION The Delphi method was innovatively adopted to establish a scoring system to predict the clinical outcome of AP. The RCSI scoring system can predict the mortality of AP better than the CTSI system, and the severity of AP equally as well.

Role of substance P and the neurokinin 1 receptor in acute pancreatitis and pancreatitis-associated lung injury

Substance P, acting via the neurokinin 1 receptor (NK1R), plays an important role in mediating a variety of inflammatory processes. However, its role in acute pancreatitis has not been previously described. We have found that, in normal mice, substance P levels in the pancreas and pancreatic acinar cell expression of NK1R are both increased during secretagogue-induced experimental pancreatitis. To evaluate the role of substance P, pancreatitis was induced in mice that genetically lack NK1R by administration of 12 hourly injections of a supramaximally stimulating dose of the secretagogue caerulein. During pancreatitis, the magnitude of hyperamylasemia, hyperlipasemia, neutrophil sequestration in the pancreas, and pancreatic acinar cell necrosis were significantly reduced in NK1R−/− mice when compared with wild-type NK1R+/+ animals. Similarly, pancreatitis-associated lung injury, as characterized by intrapulmonary sequestration of neutrophils and increased pulmonary microvascular permeability, was reduced in NK1R−/− animals. These effects of NK1R deletion indicate that substance P, acting via NK1R, plays an important proinflammatory role in regulating the severity of acute pancreatitis and pancreatitis-associated lung injury.

Activation of polyamine catabolism in transgenic rats induces acute pancreatitis

Polyamines are required for optimal growth and function of cells. Regulation of their cellular homeostasis is therefore tightly controlled. The key regulatory enzyme for polyamine catabolism is the spermidine/spermine N1-acetyltransferase (SSAT). Depletion of cellular polyamines has been associated with inhibition of growth and programmed cell death. To investigate the physiological function SSAT, we generated a transgenic rat line overexpressing the SSAT gene under the control of the inducible mouse metallothionein I promoter. Administration of zinc resulted in a marked induction of pancreatic SSAT, overaccumulation of putrescine, and appearance of N1-acetylspermidine with extensive depletion of spermidine and spermine in transgenic animals. The activation of pancreatic polyamine catabolism resulted in acute pancreatitis. In nontransgenic animals, an equal dose of zinc did not affect pancreatic polyamine pools, nor did it induce pancreatitis. Acetylated polyamines, products of the SSAT-catalyzed reaction, are metabolized further by the polyamine oxidase (PAO) generating hydrogen peroxide, which might cause or contribute to the pancreatic inflammatory process. Administration of specific PAO inhibitor, MDL72527 [N1,N2-bis(2,3-butadienyl)-1,4-butanediamine], however, did not affect the histological score of the pancreatitis. Induction of SSAT by the polyamine analogue N1,N11-diethylnorspermine reduced pancreatic polyamines levels only moderately and without signs of organ inflammation. In contrast, the combination of N1,N11-diethylnorspermine with MDL72527 dramatically activated SSAT, causing profound depletion of pancreatic polyamines and acute pancreatitis. These results demonstrate that acute induction of SSAT leads to pancreatic inflammation, suggesting that sufficient pools of higher polyamine levels are essential to maintain pancreatic integrity. This inflammatory process is independent of the production of hydrogen peroxide by PAO.

Acute hemorrhagic necrotizing pancreatitis in falciparum malaria

Malaria is a pathology caused by a parasite called Plasmodium, characteristic of tropical countries. The most frequent symptomatology includes cerebral malaria, jaundice, convulsive crisis, anemia, hypoglycemia, kidney failure and metabolic acidosis, among others. We are presenting the case of a patient diagnosed with malaria who suffered from acute hemorrhagic necrotizing pancreatitis and evolved poorly, as an example of this combination of symptoms, rarely found in our country.

Hypertonic saline reduces metalloproteinase expression in liver during pancreatitis

P>We recently demonstrated that hypertonic saline reduces inflammation and mortality in acute pancreatitis. The present study investigated the effects of hypertonic saline in metalloproteinase (MMP) regulation and pancreatitis-associated hepatic injury. Wistar rats were divided into four groups: (i) control, not subjected to insult or treatment; (ii) no treatment (NT), induction of pancreatitis (retrograde infusion of 2.5% sodium taurocholate (1.0 mL/kg)), but no further treatment; (iii) normal saline (NS), induction of pancreatitis and treatment with normal saline (0.9% NaCl, 34 mL/kg, i.v. bolus, 1 h after the induction of pancreatitis); and (iv) hypertonic saline (HS), induction of pancreatitis and treatment with hypertonic saline (7.5% NaCl, 4 mL/kg administered over a period of 5 min, 1 h after the induction of pancreatitis). In all four groups, 4, 12 and 24 h after the induction of pancreatitis, liver tissue samples were assayed to determine levels of MMP-2, MMP-9, 47 kDa heat shock protein (HSP47) and collagen (Type I and III). Compared with the control group, MMP-9 expression and activity was increased twofold in the NS and NT groups 4 and 12 h after the induction of pancreatitis, but remained at basal levels in the HS group. In contrast, MMP-2 expression was increased twofold 12 h after the induction of pancreatitis only in the NS group, whereas the expression of HSP47 was increased 4 h after the induction of pancreatitis in the NS and NT groups. Greater extracellular matrix remodelling occurred in the NS and NT groups compared with the HS group, probably as a result of the hepatic wound-healing response to repeated injury. However, the collagen content in hepatic tissue remained at basal levels in the HS group. In conclusion, the results of the present study indicate that hypertonic saline is hepatoprotective and reduces hepatic remodelling, maintaining the integrity of the hepatic extracellular matrix during pancreatitis. Hypertonic saline-mediated regulation of MMP expression may have clinical relevance in pancreatitis-associated liver injury.

A Comparison of the Consensus and Clinical Definitions of Pancreatitis With a Proposal to Redefine Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Objectives: We evaluated the correlation between the consensus and clinical definitions of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), with the objective of updating and revising the definition of post-ERCP pancreatitis (PEP). Methods: Three hundred patients were subjected to serial serum amylase & lipase levels testing and abdominal computed tomography scan for abdominal pain after ERCP. Main outcome measures included the correlation between consensus and clinical definitions. Results: Using consensus criteria, 25 patients had acute pancreatitis (11 of mild and 14 of moderate severity). Forty-three patients had acute pancreatitis using the clinical definitions (18 of mild and 25 of moderate severity). At 4 hours, serum hyperamylasemia of under 1.5-fold and at 12 hours a serum hyperamylasemia of under 2-fold had a negative predictive value of 0.94 for development of PEP. Serum hyperamylasemia following ERCP had a poor positive predictive value for PEP. Conclusions: Clinical and consensus definitions are poorly correlated; use of the latter leads to significant underrecognition of PEP. The adoption of clinical definition results in uniformity of diagnosis of pancreatitis for clinical care and research. Serum amylase levels at 4 and 12 hours after ERCP have a high negative predictive value for PEP.

Paper de la PAP en la resposta inflamatoria durant la pancreatitis aguda

Estudi elaborat a partir d’una estada al Institut national de la santé et de la recherche médicale, França, entre setembre i octubre del 2006. La PAP va ser identificada inicialment com una proteïna de secreció, que apareixia al suc pancreàtic després de la inducció d’una pancreatitis aguda experimental. Per la PAP s’ha suggerit diferents funcions, algunes no relacionades en aparença, però les més interessants en el camp de la pancreatitis són les activitats antiapoptótiques, mitogéniques i, especialment, antiinflamatóries. Per aprofundir en aquests aspectes de la PAP, s’ha emprat un model de ratolí PAP-/- per observar els efectes de la deleció del gen de la PAP durant la pancreatitis aguda.Per induir la pancreatitis es va fer servir el model de administració de ceruleina a dosi supra-màximes. En aquestes condicions es va observar que en els animals PAP-/-, la severitat del procés era menor. Els marcadors de necrosi pancreàtica, lipasa i amilasa, van presentar nivells menors en els animals PAP-/- que en els corresponents wild type. Per contra, el nombre de PMN infiltrats i la producció de citoquines pro-inflamatories va ser major en el pàncreas dels animals PAP-/-. La intensitat de la resposta inflamatòria observada suggereix que en condicions fisiològiques, el paper anti-inflamatori de la PAP es prou rellevant. Això ja s’havia suggerit en estudis in vitro, en els que es va demostrar que l’activitat antiinflamatòria de la PAP depenia de la via de transducció de senyal Jak/STAT/SOCS3. Aquesta hipòtesi s’ha comprovat in vivo, monitoritzant el nivell d’activació de STAT3 en els pàncreas dels animals després de la inducció de la pancreatitis.Tot plegat confirma que les funcions antiinflamatòries descrites in vitro per la PAP també es poden observar in vivo, de manera que la PAP sembla ser un agent important en la resposta de les cèl•lules pancreàtiques durant la pancreatitis aguda.

Boerhaave Syndrom: an unusual complication of acute vomiting in a child

Introduction: Boerhaave syndrome (BS) is a spontaneous esophageal perforation, described in aged, alcoholic males, secondary to forceful vomiting. BS has rarely been described in children. Case presentation: The patient is a 7-year-old Nigerian girl. She has a past history of clinical gastro-esophageal reflux (treated conservatively with prokinetics and good evolution), malaria at the age of 3 months and an episode of acute pancreatitis at 5 years. One week prior admission, she had stopped atovaquone-proguanil (AP) prophylaxis after a trip in an endemic area. Two days prior admission, she presented several bouts of isolated acute vomiting, without fever or diarrhea. On admission, she complained of chest pain. Cardiac auscultation revealed crepitus. No subcutaneous emphysema nor respiratory distress was present. Chest radiography and CT-scan confirmed a pneumomediastinum extending to the neck. Esophageal perforation was suspected. An upper gastrointestinal endoscopy was performed and showed a small esophageal tear, grade II-III esophagitis and a single gastric ulcer without any sign of H. Pylori infection. Enteral feeds were stopped and a nasogastric sucking tube inserted. The patient made a full recovery on intravenous antibiotics and conservative treatment. Of note a second episode of subclinical acute pancreatitis, treated conservatively, probably drug-induced. Discussion: BS is a complete rupture of all layers of the esophagus, secondary to an increased intra-abdominal pressure due to incomplete opening of the cricophayngeal sphincter occurring during vomiting or cough. Rarer causes include eosinophilic or Barrett's esophagitis, HIV and caustic ingestion. Esophageal perforation in children is rare, most of time secondary to necrotizing esophagitis in the newborn, medical intervention (endoscopy, sucking, or intubation) or trauma in the older child. Our patient had none of those risk factors and it is still unclear what predisposed her to this complication. However, we believe that preceding forceful vomiting with increased abdominal pressure acting on a weakened oesophagus due to esophagitis might be responsible. We could not find any association in the literature between AP and BS nor between BS and acute pancreatitis. The origin of her recurrent pancreatitis remains unclear, reason for which genetic testing for mutations in the trypsinogen, trypsin inhibitor and CFTR genes will be performed in case of a third episode.

Plasmapheresis as treatment for hyperlipidemic pancreatitis.

BACKGROUND Severe hypertriglyceridemia with an accumulation of chylomicrons and triglyceride figures >1000 mg/dL can cause acute pancreatitis, a potentially fatal complication. The option of rapid reduction in triglyceride concentrations is attractive and possible with plasmapheresis. METHODS We present the results of an analysis of 11 patients admitted to the intensive care unit with severe hypertriglyceridemic pancreatitis and treated with plasmapheresis. The procedure was repeated until serum triglycerides were below 1000 mg/dL. We recorded anthropometric, clinical data as well as final outcome. RESULTS In eight patients a single plasma exchange was sufficient to reduce triglyceride figures <1000 mg/dL. Only three patients died, all with the worst severity indexes and who experienced the longest delay before the procedure. CONCLUSIONS Our results, together with a review of the literature, confirm the need for a randomized clinical trial to compare conventional treatment vs. plasmapheresis in patients with severe hypertriglyceridemic pancreatitis.

Correlación entre la escala clínica de Apache II y la imagenológica de Balthazar en la evaluación de pancreatitis aguda severa en pacientes adultos de la Fundación Cardioinfantil entre 2008-2010

El diagnóstico oportuno en pancreatitis aguda es clave para abordar adecuadamente al paciente, para disminuir complicaciones. En la evaluación de la severidad de la pancreatitis, se cuenta con la escanografía; útil en la determinación de complicaciones locales; sin embargo, es necesario establecer su correlación con el curso clínico del paciente, evaluado mediante la escala APACHE II que cuenta con diversas variables. METODOLOGIA: Determinar la correlación entre las escalas clínica e imagenológica en la evaluación de severidad de la pancreatitis. Para esto, se revisan historias clínicas de la Fundación Cardio - Infantil de pacientes con pancreatitis aguda, se revisa si cumplen criterios de inclusión, y se emplea análisis estadístico descriptivo en SPSS, para establecer correlación entre las variables. RESULTADOS: Existe pobre correlación entre las variables, porque son escalas que evalúan parámetros diferentes, lo que hace que estas escalas se complementen. DISCUSION: Se analizaron 189 pacientes, de una población de 264; los restantes no cumplían criterios de inclusión. Las características demográficas y la etiología de la pancreatitis son muy similares a las descritas en otros estudios. Se tomaron paraclínicos para definir criterios de Ramson; y se les realizó escanografía abdominal para buscar complicaciones locales; de acuerdo a la escala BALTHAZAR-INDICE DE SEVERIDAD; y la evaluación clínica APACHE II, para hacer seguimiento clínico. El criterio de ingreso a UCI se evalúa con la escala APACHE II que puede hacerse periódicamente; posteriormente se evaluó coeficientes de correlación entre las variables con mayor impacto en pronóstico. PALABRAS CLAVES: Pancreatitis aguda, Severidad, Apache II, BALTHAZAR

Efecto de la restitución temprana de la nutrición oral en la pancreatitis aguda leve

Aunque el manejo nutricional de los pacientes con Pancreatitis Aguda Severa ha sido bien establecido por la evidencia disponible, el inicio de la vía oral en Pancreatitis Leve no ha sido igualmente estudiado. El objetivo de este estudio es evaluar el efecto del inicio temprano de la nutrición por vía oral en estos pacientes. Métodos: Realizamos un descriptivo serie de comparación de casos en los cuales comparamos la evolución y resultados del manejo de los pacientes con pancreatitis aguda antes y después de iniciar un protocolo de inicio temprano de nutrición por vía oral. Resultados: La serie incluyó 13 pacientes manejados con restitución convencional y 9 pacientes a quienes se restituyó tempranamente la nutrición oral. No existieron diferencias estadísticamente significativas en cuanto las características clínicas, etiológicas y demográficas entre los grupos. No se presentaron casos de progresión a enfermedad severa en ninguno de los grupos. La aparición de síntomas gastrointestinales como vomito y dolor después del inicio de la dieta fue similar en los dos grupos. Conclusiones: La restitución de la nutrición por vía oral basada criterios preestablecidos (la intensidad del dolor menor de 4 y un periodo mayor a 6 horas desde el último episodio emético) es segura y disminuye el periodo de ayuno inicial mas no el de estancia hospitalaria.