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Buldukoglu OC, Ocal S, Cekin AH. Letter to the editor regarding 'Adjuvant non-opioid analgesics decrease in-hospital mortality in targeted patients with acute pancreatitis receiving opioids'. Eur J Gastroenterol Hepatol 2025; 37:784. [PMID: 40378017 DOI: 10.1097/meg.0000000000002983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2025]
Affiliation(s)
- Osman Cagin Buldukoglu
- Department of Gastroenterology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
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Bu M, Zhang Y, Xie X, Li K, Li G, Tong Z, Li W. Influencing factor analysis and clinical efficacy of early intervention in severe acute pancreatitis with persistent organ failure. Sci Rep 2025; 15:16230. [PMID: 40346177 PMCID: PMC12064800 DOI: 10.1038/s41598-025-98532-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Accepted: 04/14/2025] [Indexed: 05/11/2025] Open
Abstract
This study aims to analyze the risk factors requiring early intervention in severe acute pancreatitis (SAP) patients with persistent organ failure and evaluate the clinical outcomes following treatment. This was a retrospective observational study. Inverse probability treatment weighting using propensity score methods was employed to balance baseline characteristics. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with early intervention. Smooth curve fitting was applied to explore potential relationships between variables and intervention timing. Threshold effect analysis was conducted to identify the optimal inflection point in nonlinear relationship. A total of 310 patients were included in this study. Compared to the standard treatment group (n = 162), the early intervention group (n = 148) had a higher proportion of multiple organ failure (77.1% vs. 63.6%, P = 0.021) and higher mortality (27.7% vs. 16.0%, P = 0.013), but early intervention was not significantly associated with adverse outcome (OR 1.52, 95% CI 0.71-3.26, P = 0.283). Risk factors associated with early intervention included computed tomography severity index, SOFA score, intra-abdominal pressure (IAP), and remifentanil equivalents. Among these, the SOFA score showed a negative linear relationship with intervention timing, while distinct threshold effects were observed between IAP, remifentanil equivalents, and intervention timing. One week after intervention, most patients showed improved organ function, along with reduced requirements for sedation and analgesia, as well as decreased C-reactive protein level levels and IAP (all P < 0.05). SAP patients requiring early intervention tended to have higher disease severity. Although early intervention can improve short-term organ function, reduce IAP, and lower analgesic requirements, its impact on reducing mortality remains uncertain.
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Affiliation(s)
- Minchun Bu
- Medical College of Yangzhou University, Yangzhou, 225000, Jiangsu Province, People's Republic of China
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu Province, People's Republic of China
| | - Yun Zhang
- Medical College of Yangzhou University, Yangzhou, 225000, Jiangsu Province, People's Republic of China
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
| | - Xiaochun Xie
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Kaiming Li
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Gang Li
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu Province, People's Republic of China.
| | - Zhihui Tong
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu Province, People's Republic of China
| | - Weiqin Li
- Medical College of Yangzhou University, Yangzhou, 225000, Jiangsu Province, People's Republic of China.
- Department of Critical Care Medicine, Center of Severe Acute Pancreatitis (CSAP), Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu Province, People's Republic of China.
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Amodio A, de Pretis N, De Marchi G, Campagnola P, Crucillà S, Caldart F, Frulloni L. Management of acute pancreatitis in the "no man's land". Intern Emerg Med 2025:10.1007/s11739-025-03916-4. [PMID: 40188404 DOI: 10.1007/s11739-025-03916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 03/03/2025] [Indexed: 04/08/2025]
Abstract
Acute pancreatitis (AP) is an inflammatory disease that can represent a challenge for clinicians, in fact, the early determination of its severity in the first 72 h is crucial for prognosis, recognizing the etiology and carrying out risk stratification to determine a more specific therapy. No accurate early prognostic scores for disease severity have been published, so the severity of AP often cannot be properly defined in the first few hours of the disease. This initial phase represents a "no man's land", in which there is no certainty in the stratification of the damage, prognosis is difficult to establish, therapy must be started promptly, although there is still no effective medical therapy against pancreatic enzymatic activation. Therefore, it is very difficult at this stage to make the correct decisions to achieve the best outcome for the patient with AP. Literature search was carried out using the PubMed database by entering early management of acute pancreatitis [title] or therapy of acute pancreatitis [title] and selecting the most relevant articles for the diagnosis and therapy of acute pancreatitis in clinical practice. This document provides suggestions on managing the key clinical decisions for patients suffering from AP before disease severity is defined, to achieve the best outcomes for patients with AP.
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Moazzami B, Mohammadpour Z, Zabala ZE, Chawla S. The Effect of Epidural Analgesia on In-hospital Outcomes in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Pancreas 2025; 54:e369-e377. [PMID: 39626190 DOI: 10.1097/mpa.0000000000002444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 11/12/2024] [Indexed: 04/14/2025]
Abstract
OBJECTIVES Acute pancreatitis (AP) can lead to severe complications and high mortality. Previous studies suggest that epidural analgesia (EA) may improve outcomes in AP. This systematic review and meta-analysis aimed to evaluate the efficacy of EA on in-hospital outcomes in AP patients. METHODS Electronic databases (PubMed, Medline-Ovid, Scopus, CINAHL, Web of Science) were systematically searched until May 2024 for RCTs comparing EA with other pain strategies in AP patients. Variables were pooled using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Data analysis employed random-effects the Mantel-Haenszel method and I 2 statistic was used for heterogeneity. RESULTS Five RCTs with 260 participants were included. Meta-analysis showed no significant differences in in-hospital mortality (RR, 0.69; 95% CI [0.29-1.65]; P = 0.40), mechanical ventilation (RR, 0.82; 95% CI [0.61-1.10]; P = 0.19), sepsis (RR, 0.88; 95% CI [0.42-1.86]; P = 0.74), hospital/ICU stay (WMD, 0.49 days; 95% CI [-1.13 to 2.10]; P = 0.55), and pain score (WMD, 1.49; 95% CI [-0.42 to 3.40]; P = 0.13). Opioid requirements were significantly lower, with one study reporting MME of 15 mg/d compared to 52 mg/d in the control group ( P = 0.001). Heterogeneity was low to moderate for most outcomes but high for pain score ( I2 = 92%). Small number of studies, risk of bias, and sample size limited overall certainity. CONCLUSIONS EA did not significantly improve in-hospital outcomes in AP patients. However, findings suggested potential benefits in pain management. High-quality randomized trials are needed to understand the potential benefits of EA in this population.
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Affiliation(s)
- Bobak Moazzami
- Internal Medicine, Graduate Medical Education-Northside Hospital Gwinnett, Lawrenceville, GA
| | - Zinat Mohammadpour
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Zohyra E Zabala
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, NY
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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Vargas A, Dutta P, Hawa F, Quingalahua E, Marin R, Vilela A, Nix T, Mendoza-Ladd A, Wilcox CM, Chalhoub JM, Machicado JD. Effect of selective COX-2 inhibitors and non-selective non-steroidal anti-inflammatory drugs on severity of acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2025:S1424-3903(25)00061-4. [PMID: 40155261 DOI: 10.1016/j.pan.2025.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 03/18/2025] [Accepted: 03/20/2025] [Indexed: 04/01/2025]
Abstract
BACKGROUND It's been suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the inflammatory response and severity of acute pancreatitis (AP). In this systematic review and meta-analysis, we aimed to explore the impact of selective COX-2 and non-selective NSAIDs compared to non-NSAID options on the severity of AP. METHODS We searched MEDLINE, EMBASE, and Cochrane Central, from database inception through September 2023. We included RCTs and observational studies comparing NSAIDs with non-NSAID controls. The primary outcome was the development of severe acute pancreatitis (SAP) characterized by persistent organ failure lasting >48 h. Secondary outcomes included mortality, pancreatic necrosis, length of stay (LOS), pain relief, and requirement for rescue analgesia. Meta-analysis was conducted separately for selective COX-2 inhibitors and non-selective NSAIDs. RESULTS Eleven studies met eligibility criteria including 1830 patients with AP. Of 3 studies that used selective NSAIDs (1 RCT and 2 observational), COX-2 inhibitors significantly reduced SAP (OR = 0.38; 95 %CI 0.27-0.52; p < 0.001; I2 = 0 %), pancreatic necrosis (OR = 0.48; 95 %CI 0.29-0.78; p = 0.003; I2 = 0 %), LOS by 5.51 days (95 %CI -10.80 to -0.22; p = 0.04; I2 = 97 %), and rescue opioids (OR = 0.32; 95 %CI 0.24-0.45; p < 0.001; I2 = 0 %). However, the certainty of the evidence was graded as low to very low using GRADE methodology. There was no significant effect of COX-2 inhibitors on mortality. Of 8 studies (all RCTs) that compared non-selective NSAIDs and non-NSAIDs, there was no difference in clinical outcomes, pain relief, and need for rescue analgesia. CONCLUSIONS Selective COX-2 inhibitors potentially mitigate disease severity and shorten hospitalization in patients with AP, while non-selective NSAIDs lack this benefit. Confirmatory large-scale RCTs are warranted to validate these findings.
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Affiliation(s)
- Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Priyata Dutta
- Department of Internal Medicine, Trinity Health, Ann Arbor, MI, USA
| | - Fadi Hawa
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Elit Quingalahua
- Department of Pediatrics, Central Michigan University, Saginaw, MI, USA
| | - Ricardo Marin
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ana Vilela
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Tyler Nix
- Division of Research and Informatics, Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Mendoza-Ladd
- Division of Gastroenterology and Hepatology, University of California Davis Health, Sacramento, CA, USA
| | - C Mel Wilcox
- Digestive Health Institute, Orlando Health, Orlando, FL, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Staten Island University Hospital, Staten Island, NY, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
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Giamouris VJ, Davenport M, Davies IH, Geaney G, Banerjee T, Bakewell C, Henderson P, Grammatikopoulos T. Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group. Frontline Gastroenterol 2025; 16:155-165. [DOI: 10.1136/flgastro-2024-102788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2025] Open
Abstract
Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.
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Guilabert L, Cárdenas-Jaén K, de-Madaria E. Initial Management of Acute Pancreatitis. Gastroenterol Clin North Am 2025; 54:21-36. [PMID: 39880529 DOI: 10.1016/j.gtc.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
The initial management of acute pancreatitis (AP) is continually evolving. Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies. Antibiotics should be administered only when there is a proven or highly probable infection rather than for prophylactic purposes. Urgent endoscopic retrograde cholangiopancreatography would be beneficial for patients with acute cholangitis. Same-admission cholecystectomy for mild biliary PA is safe, efficiently prevents relapse, and is associated with lower costs compared with interval cholecystectomy. Ongoing research into novel pharmacologic treatments and strategies is essential for further advancements in AP management.
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Affiliation(s)
- Lucía Guilabert
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/Lguilabert1
| | - Karina Cárdenas-Jaén
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/KarinaCardenasJ1
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain; Clinical Medicine Department, Miguel Hernandez University, Campus UMH de Sant Joan, Edificio Francisco Javier Balmis, Carretera Nacional 332 s/n, 03550, San Juan de Alicante, Spain.
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Liță (Cofaru) FA, Eremia IA, Nica S, Brîndușe LA, Zărnescu NO, Moldoveanu AC, Goran LG, Fierbințeanu-Braticevici C. Predictive Value of Several Parameters for Severity of Acute Pancreatitis in a Cohort of 172 Patients. Diagnostics (Basel) 2025; 15:435. [PMID: 40002586 PMCID: PMC11854639 DOI: 10.3390/diagnostics15040435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 02/08/2025] [Accepted: 02/09/2025] [Indexed: 02/27/2025] Open
Abstract
Background: The optimal management of patients with acute pancreatitis is directly related to the early detection of the mild, moderate, or severe forms of the disease, which remains a continuous challenge despite the availability of various severity scores. The aim of this study was to identify prognostic factors with the highest predictive value specific to the local patients and elaborate the score to identify the severe cases. Materials and Methods: A retrospective observational cohort study included 172 patients diagnosed with acute pancreatitis. Personal, clinical, laboratory, and imaging factors and their influence on the severity of acute pancreatitis were evaluated. Results: Etiology nonA-nonB (any etiology except unique alcoholic or biliary etiology), presence of diabetes mellitus, the pain Visual Analogue Scale (VAS), White Blood Cells (WBCs), and CRP (C-reactive protein) levels were found to be directly associated with the severity of acute pancreatitis (AP). Prediction scores were calculated to estimate disease severity using the following regression equations: Prediction Acute Pancreatitis Severity (PAPS) score I = 1.237 + 0.144 × nonA-nonB (0 = no, 1 = yes) + 0.001 × WBC1 + 0.027 × VAS0 and PAPS score II = 1.189 + 0.001 × CRP (mg/L) + 0.135 × nonA-nonB etiology (0 = no, 1 = yes) + 0.025 × VAS0 - 0.047 × CA1. The PAPS Score II demonstrated the best performance. At a cut-off value of 1.248, the score had 80% sensitivity, 80.9% specificity, a positive predictive value (PPV) of 28.6%, a negative predictive value (NPV) of 97.7%, and an accuracy of 80.8%. For a cut-off value of 221.5 mg/L, the accuracy of CRP was 81.4% for predicting severe AP. Conclusions: The PAPS score II is an easy-to-use, fast, and affordable score for determining cases of severe disease for patients diagnosed with AP.
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Affiliation(s)
- Florina Alexandra Liță (Cofaru)
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (F.A.L.); (A.C.M.); (L.G.G.); (C.F.-B.)
- Emergency Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
| | - Irina Anca Eremia
- Emergency Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
- Department of Family Medicine III, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Silvia Nica
- Emergency Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania;
- Department of Emergency and First Aid, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Lăcrămioara Aurelia Brîndușe
- Department of Public Health and Management, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Narcis-Octavian Zărnescu
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Second Department of Surgery, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Alexandru Constantin Moldoveanu
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (F.A.L.); (A.C.M.); (L.G.G.); (C.F.-B.)
| | - Loredana Gabriela Goran
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (F.A.L.); (A.C.M.); (L.G.G.); (C.F.-B.)
| | - Carmen Fierbințeanu-Braticevici
- Internal Medicine II and Gastroenterology Department, Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (F.A.L.); (A.C.M.); (L.G.G.); (C.F.-B.)
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Ji W, Sun L, Huang Y, Bai J, Zheng J, Zhang K. Oxycodone for analgesia in children undergoing endoscopic retrograde cholangiopancreatography: a randomized, double-blind, parallel study. Front Pharmacol 2025; 15:1515501. [PMID: 39845794 PMCID: PMC11751031 DOI: 10.3389/fphar.2024.1515501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 12/13/2024] [Indexed: 01/24/2025] Open
Abstract
Background Postoperative visceral pain is a common complication after endoscopic retrograde cholangiopancreatography (ERCP). In this study, we compared the analgesic and anti-inflammatory effects of oxycodone and fentanyl in children undergoing ERCP. Methods A single-center, randomized, double-blind study was conducted at a tertiary care hospital affiliated with Shanghai Jiao Tong University. Eighty-two pediatric patients aged 2-18 years who were scheduled for elective ERCP were randomly assigned to receive either oxycodone (0.2 mg/kg) or fentanyl (2 μg/kg). The postoperative pain was evaluated after 10 min, 20 min, and 30 min in the post-anesthesia care unit (PACU) as well as 6 h and 24 h in the ward following ERCP. Additionally, inflammatory cytokines in the serum, including tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 were examined by blood sampling at baseline, 6 h, and 24 h after ERCP. Results Compared to fentanyl, children receiving oxycodone had significantly lower pain scores at 30 min, 6 h, and 24 h after ERCP, while the scores at 10 and 20 min were similar in both groups. We also found that fewer patients had pain scores ≥3 at 6 h and 24 h after the procedure in the oxycodone group [36.6% (15/41) vs. 61.0% (25/41) at 6 h, 34.1% (14/41) vs. 58.5% (24/41) at 24 h, p = 0.027 for both cases]. Furthermore, fewer children in the oxycodone group had elevated inflammatory cytokines (IL-6 at 6 h and TNF-α at 24 h after ERCP) compared to the fentanyl group. The incidence of postoperative vomiting was also lower among children receiving oxycodone [14.1% (7/41) vs. 24.4% (10/41), p = 0.032]. Conclusion Oxycodone (0.2 mg kg-1) can provide effective analgesia and stable hemodynamics in children undergoing ERCP. This analgesic characteristic may be related to amelioration of inflammation after ERCP. Clinical Trial Registration www.chictr.org.cn, identifier ChiCTR2300074473.
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Affiliation(s)
- Wei Ji
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
| | - Liping Sun
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
| | - Yue Huang
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
| | - Jie Bai
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
| | - Kan Zhang
- Department of Anesthesiology and Pediatric Clinical Pharmacology Laboratory, Shanghai Children’s Medical Center, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Children’s Medical Center, Shanghai, China
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Lucocq J, Joseph N, Knoph CS, Abu-El-Haija M, Scheers I, Drewes AM, Pandanaboyana S. Analgesia in paediatric acute pancreatitis: A scoping systematic review. J Pediatr Gastroenterol Nutr 2025; 80:203-208. [PMID: 39563649 DOI: 10.1002/jpn3.12418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/28/2024] [Accepted: 09/08/2024] [Indexed: 11/21/2024]
Abstract
OBJECTIVE Acute pancreatitis (AP) is a common paediatric condition, yet there is little data to support optimal analgesic practice. The aim of this scoping review was to report analgesic practice, investigate trends in analgesic strategy and evaluate the impact of analgesic modality on outcomes. METHODS A systematic search of Medline, Embase, CENTRAL, Pubmed Central and Google Scholar was performed by two independent investigators. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. RESULTS Three retrospective cohort studies, all conducted in North America, reported on analgesic practice in paediatric AP. The studies included 658 patients (median age, 12 years; female sex, 57%; non-biliary aetiology, 85.9%). Overall, analgesia was administered in 67% of patients, including opioids in 59.5% (43.8%-71.4%). Rates of acetaminophen (17.9% and 77.7%) and non-steroidal anti-inflammatory drugs (7.7% and 40.2%) were reported in two studies. Two studies reported reducing rates of opioid administration or reduced duration of opioid administration since 2017 and 2014, respectively. One study did not find any correlation between opioid administration and sociodemographic factors, length of stay or admission to intensive care units. No studies reported on complications or quality of life. No studies investigated non-medical modalities. There were no long-term data on analgesic use post-discharge. CONCLUSIONS Opioids are the mainstay of pain treatment in paediatric AP in North America. However, factors that influence the analgesic type, the impact of analgesic modality on the post-pancreatitis outcome and long-term analgesic use constitute a knowledge gap. Future studies are needed to inform analgesic use in paediatric AP.
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Nejo Joseph
- Palmerston North Hospital, Health New Zealand, Midcentral, Palmerston North, New Zealand
| | - Cecilie Sigaard Knoph
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University, Aalborg, Denmark
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Isabelle Scheers
- Paediatric Gastroenterology and Hepatology, Centre for Rare Pancreatic Diseases, Cliniques universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Asbjorn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University, Aalborg, Denmark
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Hospitals and NHS Foundation Trust, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
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11
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Grover AS, Wilschanski M. Pain management in pediatric acute pancreatitis: An area of need. J Pediatr Gastroenterol Nutr 2025; 80:12-13. [PMID: 39575825 DOI: 10.1002/jpn3.12417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Revised: 11/03/2024] [Accepted: 11/04/2024] [Indexed: 01/11/2025]
Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Mihoc T, Latcu SC, Secasan CC, Dema V, Cumpanas AA, Selaru M, Pirvu CA, Valceanu AP, Zara F, Dumitru CS, Novacescu D, Pantea S. Pancreatic Morphology, Immunology, and the Pathogenesis of Acute Pancreatitis. Biomedicines 2024; 12:2627. [PMID: 39595191 PMCID: PMC11591934 DOI: 10.3390/biomedicines12112627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 11/15/2024] [Accepted: 11/15/2024] [Indexed: 11/28/2024] Open
Abstract
Acute pancreatitis is a complex inflammatory disorder with significant morbidity and mortality. This review aims to integrate the current knowledge of pancreatic morphology and immunology with the pathogenesis of acute pancreatitis, providing a comprehensive understanding of this critical condition. We conducted an extensive literature review, synthesizing data from recent studies and authoritative sources on pancreatic anatomy, histology, immunology, and the pathophysiology of acute pancreatitis. We also incorporated epidemiological data, clinical features, diagnostic criteria, and prognostic factors. The pancreas exhibits a complex morphology with intricate interactions between its exocrine and endocrine components. Its unique immunological landscape plays a crucial role in maintaining homeostasis and orchestrating responses to pathological conditions. In acute pancreatitis, the disruption of intracellular calcium signaling leads to premature enzyme activation, triggering a cascade of events including mitochondrial dysfunction, ATP depletion, and the release of proinflammatory mediators. This process can escalate from localized inflammation to systemic complications. The interplay between pancreatic morphology, immune responses, and pathophysiological mechanisms contributes to the varied clinical presentations and outcomes observed in acute pancreatitis. Understanding the intricate relationships between pancreatic morphology, immunology, and the pathogenesis of acute pancreatitis is crucial for developing more effective diagnostic and therapeutic strategies. This integrated approach provides new insights into the complex nature of acute pancreatitis and may guide future research directions in pancreatic disorders.
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Affiliation(s)
- Tudorel Mihoc
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (T.M.); (V.D.)
- Department X, General Surgery II, Discipline of Surgical Emergencies, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (M.S.); (C.A.P.); (A.P.V.); (S.P.)
| | - Silviu Constantin Latcu
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (T.M.); (V.D.)
- Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (C.-C.S.); (A.A.C.)
| | - Cosmin-Ciprian Secasan
- Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (C.-C.S.); (A.A.C.)
| | - Vlad Dema
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (T.M.); (V.D.)
- Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (C.-C.S.); (A.A.C.)
| | - Alin Adrian Cumpanas
- Department XV, Discipline of Urology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (C.-C.S.); (A.A.C.)
| | - Mircea Selaru
- Department X, General Surgery II, Discipline of Surgical Emergencies, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (M.S.); (C.A.P.); (A.P.V.); (S.P.)
| | - Catalin Alexandru Pirvu
- Department X, General Surgery II, Discipline of Surgical Emergencies, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (M.S.); (C.A.P.); (A.P.V.); (S.P.)
| | - Andrei Paul Valceanu
- Department X, General Surgery II, Discipline of Surgical Emergencies, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (M.S.); (C.A.P.); (A.P.V.); (S.P.)
| | - Flavia Zara
- Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (F.Z.); (C.-S.D.); (D.N.)
- Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Cristina-Stefania Dumitru
- Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (F.Z.); (C.-S.D.); (D.N.)
- Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Dorin Novacescu
- Department II of Microscopic Morphology, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (F.Z.); (C.-S.D.); (D.N.)
- Angiogenesis Research Center, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Stelian Pantea
- Department X, General Surgery II, Discipline of Surgical Emergencies, Victor Babes University of Medicine and Pharmacy Timisoara, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (M.S.); (C.A.P.); (A.P.V.); (S.P.)
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Wang H, Gao J, Wen L, Huang K, Liu H, Zeng L, Zeng Z, Liu Y, Mo Z. Ion channels in acinar cells in acute pancreatitis: crosstalk of calcium, iron, and copper signals. Front Immunol 2024; 15:1444272. [PMID: 39606246 PMCID: PMC11599217 DOI: 10.3389/fimmu.2024.1444272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 10/25/2024] [Indexed: 11/29/2024] Open
Abstract
The initial stages of acute pancreatitis (AP) are characterized by a significant event - acinar ductal metaplasia (ADM). This process is a crucial feature of both acute and chronic pancreatitis, serving as the first step in the development of pancreatic cancer. Ion channels are integral transmembrane proteins that play a pivotal role in numerous biological processes by modulating ion flux. In many diseases, the expression and activity of ion channels are often dysregulated. Metal ions, including calcium ions (Ca2+), ferrous ions (Fe2+), and Copper ions (Cu2+), assume a distinctive role in cellular metabolism. These ions possess specific biological properties relevant to cellular function. However, the interactions among these ions exacerbate the imbalance within the intracellular environment, resulting in cellular damage and influencing the progression of AP. A more in-depth investigation into the mechanisms by which these ions interact with acinar cells is essential for elucidating AP's pathogenesis and identifying novel therapeutic strategies. Currently, treatment for AP primarily focuses on pain relief, complications prevention, and prognosis improvement. There are limited specific treatments targeting acinous cell dedifferentiation or ion imbalance. This study aims to investigate potential therapeutic strategies by examining ion crosstalk within acinar cells in the context of acute pancreatitis.
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Affiliation(s)
- Hanli Wang
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Jianhua Gao
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Lingling Wen
- Key Laboratory of Quantitative Synthetic Biology, Shenzhen Institute of Synthetic Biology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Kejun Huang
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Huixian Liu
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Linsheng Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Zhongyi Zeng
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Yuxiang Liu
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Zhizhun Mo
- Emergency Department, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024; 19:2091-2104. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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David SN, Murali V, Kattumala PD, Abhilash KPP, Thomas A, Chowdury SD, Karuppusami R. EASIER trial (Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room): a single-centre open-label cohort-based randomised controlled trial analysing the efficacy of the ultrasound-guided erector-spinae plane block compared with intravenous morphine in the treatment of acute hepatopancreaticobiliary pain in the emergency department. Emerg Med J 2024; 41:588-594. [PMID: 38977292 PMCID: PMC11503039 DOI: 10.1136/emermed-2023-213799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Ultrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED. METHODS This open-label randomised controlled trial was conducted in the ED of a tertiary-care hospital between March and August 2023. All adult patients with severe HPB pain were recruited during times that a primary investigator was present. Unconsenting patients, numeric rating scale (NRS) ≤6, age ≤18 and ≥80 years, pregnant, unstable or with allergies to local anaesthetics or opioids were excluded. Patients in the intervention arm received bilateral USG ESPB with 0.2% ropivacaine at T7 level, by a trained ED consultant, and those in the control arm received 0.1 mg/kg intravenous morphine. Pain on a 10-point NRS was assessed by the investigators at presentation and at 1, 3, 5 and 10 hours after intervention by the treatment team, along with rescue analgesia requirements and patient satisfaction. Difference in NRS was analysed using analysis of co-variance (ANCOVA) and t-tests. RESULTS 70 participants were enrolled, 35 in each arm. Mean age was 40.4±13.2 years, mean NRS at presentation in the intervention arm was 8.0±0.9 and 7.6±0.6 in the control arm. NRS at 1 hour was significantly lower in the ESPB group (ANCOVA p<0.001). At 1, 3, 5 and 10 hours, reduction of NRS in the intervention arm (7±1.6, 6.7±1.9, 6.6±1.8, 6.1±1.9) was significantly greater than the control arm (4.4±2, 4.6±1.8, 3.7±2.2, 3.8±1.8) (t-test, p<0.001). Fewer patients receiving ESPB required rescue analgesia at 5 (t-test, p=0.031) and 10 hours (t-test, p=0.04). More patients were 'very satisfied' with ESPB compared with receiving only morphine at each time period (p<0.001). CONCLUSION ESPB is a promising alternative to morphine in those with HPB pain. TRIAL REGISTRATION NUMBER CTRI/2023/03/050595.
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Affiliation(s)
- Sandeep Nathanael David
- Department of Emergency Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Vignesh Murali
- Department of Emergency Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Pradeep Daniel Kattumala
- Department of Emergency Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | | | - Ajith Thomas
- Department of Clinical Gastroenterology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Sudipta Dhar Chowdury
- Department of Clinical Gastroenterology, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
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Brasky TM, Jager LR, Newton AM, Li X, Loomans-Kropp HA, Hays JL, Margolis KL, Luo J. Use of Nonsteroidal Anti-Inflammatory Drugs and Pancreatic Cancer Risk in the Women's Health Initiative. Cancer Epidemiol Biomarkers Prev 2024; 33:1203-1210. [PMID: 38900510 PMCID: PMC11371515 DOI: 10.1158/1055-9965.epi-24-0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/03/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Pancreatic cancer is among the most fatal human cancers and the fourth leading cause of cancer death in the United States. Evidence suggests that chronic inflammation may play a role in pancreatic carcinogenesis and its inhibition through nonsteroidal anti-inflammatory drugs (NSAID) may reduce pancreatic cancer incidence. METHODS We examined associations of total and individual NSAIDs with pancreatic cancer risk among postmenopausal women participating in the Women's Health Initiative observational study and clinical trial cohorts. Among 117,452 women, aged 55 to 79 years, 727 incident pancreatic cancer cases were reported over 18 years of follow-up. Cox regression was used to estimate hazard ratio (HR) and 95% confidence interval (CI) for associations between NSAIDs and pancreatic cancer risk. RESULTS Relative to non-use, consistent use of any NSAID was inversely associated with pancreatic cancer risk (HR 0.71, 95% CI, 0.59-0.87), primarily driven by strong associations for aspirin use (HR 0.67, 95% CI, 0.52-0.86). Use of total or individual non-aspirin NSAIDs was not associated with pancreatic cancer. Upon stratified analysis, we observed stronger associations for NSAIDs among participants with prevalent diabetes (HR 0.28, 95% CI, 0.10-0.75) relative to those without (HR 0.75, 95% CI, 0.61-0.92; P-interaction = 0.03). CONCLUSIONS Additional large prospective studies with careful measurement of NSAID type, dose, and frequency are needed to further investigate the possibility of added benefit among individuals diagnosed with diabetes. IMPACT This study adds to existing evidence from prospective studies and clinical trials suggesting that use of aspirin may provide moderate benefit for pancreatic cancer prevention.
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Affiliation(s)
- Theodore M. Brasky
- Division of Medical Oncology, The Ohio State University College of Medicine; Columbus, OH, USA
- The Ohio State University – Comprehensive Cancer Center, Cancer Control Research Program; Columbus, OH, USA
| | - Leah R. Jager
- Division of Public Health Sciences, Fred Hutchinson Cancer Center; Seattle, WA, USA
| | - Alison M. Newton
- Division of Medical Oncology, The Ohio State University College of Medicine; Columbus, OH, USA
- The Ohio State University – Comprehensive Cancer Center, Cancer Control Research Program; Columbus, OH, USA
| | - Xilin Li
- Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, IN, USA
| | - Holli A. Loomans-Kropp
- The Ohio State University – Comprehensive Cancer Center, Cancer Control Research Program; Columbus, OH, USA
- Division of Cancer Prevention and Control, The Ohio State University College of Medicine; Columbus, OH, USA
| | - John L. Hays
- Division of Medical Oncology, The Ohio State University College of Medicine; Columbus, OH, USA
| | | | - Juhua Luo
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN, USA
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Subramani SS, Berg AC, Kral LA, Murad MH, Smith A, Phillips AE, Yadav D, Uc A, Imdad A. Analgesia for the treatment of acute pancreatitis: a protocol for a systematic review and network meta-analysis. BMJ Open 2024; 14:e081971. [PMID: 38740508 PMCID: PMC11097890 DOI: 10.1136/bmjopen-2023-081971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Gastrointestinal hospitalisations in the USA cause over US$130 billion in expenditures, and acute pancreatitis is a leading cause of these hospitalisations. Adequate pain control is one of the primary treatment goals for acute pancreatitis. Though opioids are commonly used for analgesia in these patients, there have been concerns about short-term and long-term side effects of using opioids. Recently, non-opioid medications have been studied to treat pain in patients with acute pancreatitis. This systematic review and network meta-analysis aims to assess the comparative efficacy of analgesic medication for non-severe, acute pancreatitis. METHODS AND ANALYSIS We will search multiple electronic databases for randomised controlled trials that study pain management in patients with non-severe, acute pancreatitis. The intervention will be any analgesic for acute pancreatitis in the hospital setting. The comparison group will be patients who received a placebo or other active interventions for pain management. The primary outcomes of interest include pain scores and the need for supplementary analgesia. The secondary outcomes will be serious adverse events, local complications, progression to severe pancreatitis, transfer to the intensive care unit, length of hospitalisation, time to start enteral feeds, 30-day all-cause mortality and Quality of Life Scale scores. If sufficient homogeneity exists among included studies, the findings will be pooled using a traditional pairwise and network meta-analysis. The risk of bias in randomised control trials will be evaluated using the Cochrane Risk of Bias Tool 2.0. The Grading of Recommendations, Assessment, Development, and Evaluation approach will be used to report the certainty of evidence. ETHICS AND DISSEMINATION This systematic review will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal. They will give healthcare providers a better awareness of the optimal analgesic medication for pain treatment in non-severe, acute pancreatitis.
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Affiliation(s)
- Sriya S Subramani
- Stead Family Department of Pediatrics, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Alaina C Berg
- The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Lee A Kral
- Department of Anesthesia, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Mohammad Hassan Murad
- Department of Internal Medicine, Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abigail Smith
- Health Science Library, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Anna Evans Phillips
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Aliye Uc
- Stead Family Department of Pediatrics, Radiation Oncology, Fraternal Order of Eagles Diabetes Research Center, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Aamer Imdad
- Stead Family Department of Pediatrics, Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
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Thierens NDE, Demir IE. How safe are opioids in the early phase of acute pancreatitis? United European Gastroenterol J 2024; 12:281-282. [PMID: 38334426 PMCID: PMC11017756 DOI: 10.1002/ueg2.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Affiliation(s)
- Naomi D. E. Thierens
- Department of Gastroenterology and HepatologyRadboudumcNijmegenNetherlands
- Department of Research and DevelopmentSt. Antonius ZiekenhuisNieuwegeinNetherlands
| | - Ihsan Ekin Demir
- Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenMunichGermany
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Shapkin MA, Sholin IY, Cherpakov RA, Suryakhin VS, Koriachkin VA, Safin RR. Erector spinae plane block as a component of intensive care for acute pancreatitis: a prospective randomized pilot study. REGIONAL ANESTHESIA AND ACUTE PAIN MANAGEMENT 2024; 18:73-84. [DOI: 10.17816/ra625466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
BACKGROUND: Analgesia is crucial in the treatment of patients with acute pancreatitis, which includes the increased use of regional analgesia. In recent years, less-invasive and safer methods of pain relief, particularly erector spinae plane block (ESP-block), has drawn attention from the anesthesiological community. However, studies on its use in acute pancreatitis are rare.
OBJECTIVE: Our aim was to make a clinical evaluation of bilateral erector spinae plane block in patients with acute pancreatitis.
MATERIALS AND METHODS: A pilot prospective randomized study was conducted. The patients were divided into two groups: group 1 (n=7), ESP blockade was used, and group 2 (n=12), epidural analgesia (EA) was used. The primary points were considered to be an assessment of pain syndrome intensity and the need for analgesics. Additional results were liver and kidney function, acid-base condition, inflammatory response level, and the time of onset of peristalsis.
RESULTS: The decrease in pain intensity in both groups was unidirectional: after 8 h, it was 3.57±1.98 points to the NRS in group 1 and 2.91±1.97 points to the NRS in group 2, and after 24 h, it was 1.42±1.27 and 1.75±2.3 points to the NRS, respectively. No significant difference was found in pain intensity between the groups (р 0,05). The average consumption of ketorolac was 78.2±16.3 mg in group 2 — 63.28±17.23 mg for 1 patient. The average need for narcotic analgesics, that is, morphine, per patient was 22±8 mg in group 1 and 36.3±17.2 mg in group 2 (р 0,05). During the therapy, blood α-amylase, diuresis rate, creatinine level, and glomerular filtration rate did not have a significant difference between the groups, as well as pH, BE, and blood lactate levels (р 0,05). Peristalsis was noted after 12.49±19.73 h in the ESP-block group and after 16.9±21.3 h in the 2nd group (р 0,05). The ICU length of stay between the groups did not differ and was 62±3 and 62±7 h, respectively (р 0,05).
CONCLUSION: Bilateral erector spinae plane block is a simple and safe method that induces analgesic effect and effect on homeostasis in acute pancreatitis, similar to epidural blockade. Further study of the role and location of erector spinae plane block in treating pain in acute pancreatitis is required.
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Affiliation(s)
| | | | - Rostislav A. Cherpakov
- Federal Scientific and Clinical Center for Reanimatology and Rehabilitation
- Sklifosovsky Research Institute for Emergency Medicine
| | | | - Victor A. Koriachkin
- St. Petersburg State Pediatric Medical University
- Kazan (Volga Region) Federal University
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20
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Hussain A, Augustine SW, Pyakurel S, Vempalli H, Dabbara R, O'dare RA, Ayush, Varghese JJ, Inban P, Jayan M, Osigwe EC, Sunkara SM, Khan A. Acute Pancreatitis Induced by COVID-19 Vaccine: A Systematic Review. Cureus 2024; 16:e55426. [PMID: 38571842 PMCID: PMC10990070 DOI: 10.7759/cureus.55426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 04/05/2024] Open
Abstract
Acute pancreatitis, marked by sudden inflammation of the pancreas, presents a complex spectrum of causative factors including gallstone obstruction, alcohol abuse, and viral infections. Recent studies have illuminated the emergence of vaccine-induced acute pancreatitis, notably associated with COVID-19 vaccinations, presenting diverse mechanisms ranging from direct viral-mediated injury to autoimmune reactions. Understanding this link is pivotal for public health, yet challenges persist in identifying and managing cases post-vaccination. Comprehensive literature reviews employing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement outline the potential pathways and mechanisms leading to vaccine-induced pancreatitis, emphasizing the need for deeper investigations into underlying health conditions and modifications to vaccine components. Notably, the rare occurrences of vaccine-induced pancreatitis extend beyond COVID-19 vaccines, with reports also documenting associations with measles, mumps, and rubella (MMR), human papillomavirus (HPV), and other viral vaccinations. Mechanistically, hypotheses such as molecular mimicry and immunologic injury have been proposed, necessitating ongoing vigilance and exploration. Regulatory agencies play a crucial role in monitoring and communicating vaccine safety concerns, emphasizing transparency to address potential risks and maintain public trust. Understanding and communicating these rare adverse events with transparency remain integral for informed vaccination policies and to allay concerns surrounding vaccine safety.
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Affiliation(s)
- Akbar Hussain
- Internal Medicine, Appalachian Regional Health, Harlan, USA
| | - Sana W Augustine
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Sandhya Pyakurel
- Internal Medicine, University of Science and Technology Chittagong, Chittagong, BGD
| | | | - Rishika Dabbara
- Internal Medicine, Kamineni Institute of Medical Sciences, Hyderabad, IND
| | - Rachel A O'dare
- Nursing, South University, Savannah, USA
- General Medicine, Medical University of Graz, Graz, AUT
| | - Ayush
- Internal Medicine, National Capital Region Institute of Medical Sciences, Meerut, IND
| | | | - Pugazhendi Inban
- General Medicine, Government Medical College, Omandurar Government Estate, Chennai, IND
| | - Malavika Jayan
- Internal Medicine, Bangalore Medical College and Research Institute, Bangalore, IND
| | | | | | - Aadil Khan
- Trauma Surgery, OSF Healthcare Hospital, University of Illinois College of Medicine, Peoria, USA
- Internal Medicine, Lala Lajpat Rai (LLR) Hospital, Kanpur, IND
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Wu Y, Han C, Luo R, Cai W, Xia Q, Jiang R, Ferdek PE, Liu T, Huang W. Molecular mechanisms of pain in acute pancreatitis: recent basic research advances and therapeutic implications. Front Mol Neurosci 2023; 16:1331438. [PMID: 38188196 PMCID: PMC10771850 DOI: 10.3389/fnmol.2023.1331438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024] Open
Abstract
Although severe abdominal pain is the main symptom of acute pancreatitis, its mechanisms are poorly understood. An emerging body of literature evidence indicates that neurogenic inflammation might play a major role in modulating the perception of pain from the pancreas. Neurogenic inflammation is the result of a crosstalk between injured pancreatic tissue and activated neurons, which leads to an auto-amplification loop between inflammation and pain during the progression of acute pancreatitis. In this review, we summarize recent findings on the role of neuropeptides, ion channels, and the endocannabinoid system in acute pancreatitis-related pain. We also highlight potential therapeutic strategies that could be applied for managing severe pain in this disease.
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Affiliation(s)
- Yongzi Wu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chenxia Han
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rong Luo
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenhao Cai
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Xia
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ruotian Jiang
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Pawel E. Ferdek
- Department of Cell Biology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland
| | - Tingting Liu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
- Institutes for Systems Genetics and Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- West China Biobank, West China Hospital, Sichuan University, Chengdu, China
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22
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Abstract
PURPOSE OF REVIEW This review provides insight into the recent advancements in the management of acute pancreatitis. RECENT FINDINGS Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. SUMMARY More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.
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Affiliation(s)
- Fons F. van den Berg
- Amsterdam UMC location University of Amsterdam, Medical Microbiology & Infection prevention
| | - Marja A. Boermeester
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9
- Amsterdam institute for Infection and Immunity
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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24
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Almulhim M, Almulihi QA, Almumtin HS, Alghanim MH, AlAbdulbaqi DA, Almulihi FAA. The Efficacy and Safety of Using Opioids in Acute Pancreatitis: an Update on Systematic Review and Meta-Analysis. Med Arch 2023; 77:281-287. [PMID: 37876565 PMCID: PMC10591254 DOI: 10.5455/medarh.2023.77.281-287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/05/2023] [Indexed: 10/26/2023] Open
Abstract
Background Most patients with acute pancreatitis (AP) suffer from abdominal pain that requires immediate pain relief, and there are various medication choices available, with opioids being the most prescribed analgesics. Objective Our objective is to compare the use of opioids with other medications in emergency settings for managing pain in patients with AP. Methods A systemic search was conducted in electronic databases (PubMed/Medline, Cochrane Library, Embase and Google Scholar) from inception to Feb 2023. All statistical analyses were conducted in Review Manager 5.4.1. The study's inclusion criteria was then selected. Only those Randomized Controlled Trials were involved that included patients having AP in an emergency setting. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the Odds Ratio (OR) and Mean Difference (MD) along with the corresponding 95% confidence interval (CI). Narrative analysis was conducted for those variables which did not have sufficient data be included in the quantitative analysis. Results We include eight Randomized Controlled Trials in our study. The Pooled result showed non-significant differences in adverse effects between the two interventions (OR 1.42 [95% CI 0.62, 3.23]; p value= 0.40; I2= 20%). While overall, significantly additional drugs were used in the control group (OR 0.22 [95% CI 0.06, 0.85]; p value= 0.03; I2= 72%). Pain score and severity levels were also analyzed. We used a narrative approach to analyze the length of stay, mean time to reach significant decrease in pain, and mortality, which were all non-conclusive. We also narratively assessed the Pediatric population. Conclusion Opioids do not provide significant superiority over other medications and should be avoided due to their addictive nature.
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Affiliation(s)
- Mohamed Almulhim
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Qasem Ahmed Almulihi
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
- Department, King Fahad University Hospital, Al Khobar, Saudi Arabia
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25
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Chan KS, Shelat VG. Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies. World J Gastrointest Surg 2022; 14:1179-1197. [PMID: 36504520 PMCID: PMC9727576 DOI: 10.4240/wjgs.v14.i11.1179] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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26
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Szatmary P, Grammatikopoulos T, Cai W, Huang W, Mukherjee R, Halloran C, Beyer G, Sutton R. Acute Pancreatitis: Diagnosis and Treatment. Drugs 2022; 82:1251-1276. [PMID: 36074322 PMCID: PMC9454414 DOI: 10.1007/s40265-022-01766-4] [Citation(s) in RCA: 228] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
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Affiliation(s)
- Peter Szatmary
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Wenhao Cai
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool , UK
| | - Chris Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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27
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Chen Z, Jiang K, Liu F, Zhu P, Cai F, He Y, Jin T, Lin Z, Li Q, Hu C, Tan Q, Yang X, Guo J, Huang W, Deng L, Xia Q. Safety and efficacy of intravenous hydromorphone patient-controlled analgesia versus intramuscular pethidine in acute pancreatitis: An open-label, randomized controlled trial. Front Pharmacol 2022; 13:962671. [PMID: 35991892 PMCID: PMC9387897 DOI: 10.3389/fphar.2022.962671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Hydromorphone patient-controlled analgesia (PCA) provides satisfactory postoperative pain therapy, but its effect has not been assessed in acute pancreatitis (AP).Aim: To assess the safety and efficacy of intravenous hydromorphone PCA for pain relief in AP.Methods: This open-label trial included AP patients admitted within 72 h of symptom onset, aged 18–70 years old, and with Visual Analog Scale (VAS) for pain intensity ≥5. They were randomized to receive intravenous hydromorphone PCA (0.05 mg/h with 0.2 mg on-demand) or intramuscular pethidine (50 mg as required) for three consecutive days. Intramuscular dezocine (5 mg on demand) was the rescue analgesia. The primary outcome was the change of VAS score recorded every 4 h for 3 days. Interim analysis was conducted by an Independent Data and Safety Monitoring Committee (IDSMC).Results: From 26 July 2019 to 15 January 2020, 77 patients were eligible for the intention-to-treat analysis in the interim analysis (39 in the hydromorphone group and 38 in the pethidine group). Baseline parameters were comparable between groups. No difference in VAS between the two groups was found. Hydromorphone PCA was associated with higher moderately severe to severe cases (82.1% vs. 55.3%, p = 0.011), acute peripancreatic fluid collections (53.9% vs. 28.9%, p = 0.027), more cumulative opioid consumption (median 46.7 vs. 5 mg, p < 0.001), higher analgesia costs (median 85.5 vs. 0.5 $, p < 0.001) and hospitalization costs (median 3,778 vs. 2,273 $, p = 0.007), and more adverse events (20.5% vs. 2.6%, p = 0.087). The per-protocol analysis did not change the results. Although a sample size of 122 patients was planned, the IDSMC halted further recruitment as disease worsening or worse clinical outcomes between the groups in the interim analysis.Conclusion: Hydromorphone PCA was not superior to pethidine in relieving pain in AP patients and might have worse clinical outcomes. Therefore, its use is not recommended.Clinical Trial Registration: Chictr.org.cn. ChiCTR1900025971
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Affiliation(s)
- Zhiyao Chen
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Jiang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Zhu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Cai
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yanqiu He
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Jin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqi Lin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Hu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyuan Tan
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaonan Yang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jia Guo
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Lihui Deng
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Qing Xia
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
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Nair A, Tiwary MK, Seelam S, Kothapalli KK, Pulipaka K. Efficacy and Safety of Thoracic Epidural Analgesia in Patients With Acute Pancreatitis: A Narrative Review. Cureus 2022; 14:e23234. [PMID: 35449658 PMCID: PMC9012692 DOI: 10.7759/cureus.23234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
Patients admitted to the intensive care unit with moderate to severe acute pancreatitis carry significant morbidity and mortality. A few unfortunate patients in whom the initial line of treatment fails to show clinical improvement develop multiorgan dysfunction involving lungs (adult respiratory distress syndrome), renal failure, intra-abdominal infections, sepsis, and septic shock, which ultimately leads to prolonged hospitalization and a substantial cost of treatment. The acute abdominal pain experienced by these patients is excruciating and requires multimodal analgesia. Continuous epidural analgesia has been found to provide good quality, opioid-sparing analgesia in these patients. A few studies have also demonstrated that segmental sympathectomy resulting from epidural blockade could lead to lowering of serum amylase and lipase levels improve paralytic ileus, and thus hastens the process of recovery. The present paper aims to discuss the advantages of continuous epidural analgesia in patients with acute pancreatitis of varying severity and to review the existing literature using specific keywords.
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