Hana Nechutová

Could rising BUN predict the future development of infected pancreatic necrosis

BACKGROUND Infected (peri)pancreatic necrosis (IPN) in acute pancreatitis (AP) is associated with organ failure (OF) and high mortality. There are no established early markers of primary IPN. This study aimed to assess the association of simple parameters with primary IPN in AP. METHODS We retrospectively studied 281 patients with AP admitted to Mayo Clinic hospitals and identified those with microbiologically confirmed infections in (peri)pancreatic necrosis and collections. We defined primary IPN as infection of (peri)pancreatic necrotic tissue that developed before interventions. We recorded admission hematocrit, BMI, BUN, serum creatinine, SIRS score and development of persistent organ failure within 48 h of admission; and performed serial SIRS and BUN calculations for at least 48 h. We used univariate and multivariable analysis to assess associations and expressed results as odds ratio (OR)[95% CI]. RESULTS 27 (9.6%) patients developed IPN, of which 21 (77.7%) had primary IPN. 38.1% had Gram positive, 9.5% Gram negative and 52.3% mixed bacterial infections. Five (23.8%) of the patients with IPN had fungal infection. On univariate analysis, SIRS ≥ 2 at admission, rise in BUN by 5 mg/dL within 48 h of admission, persistence of SIRS for 48 h and development of persistent OF within 48 h of disease had significant association with development of primary IPN with OR (95% CI) of 4.12 (1.53-11.15), 10.25 (3.95-26.61), 1.19 (1.69-10.39) and 7.62 (2.58-21.25) [2-tailed p = 0.004, <0.0001, 0.002 and <0.0001] respectively. On multivariable analysis, only rise in BUN by 5 mg/dL within 48 h of admission was associated with primary IPN (p = 0.007). CONCLUSIONS Rising BUN within 48 h of admission can be used to predict development of primary IPN in AP.

Autoimmune pancreatitis--recent advances.

Autoimmune pancreatitis (AIP) is recognized as a distinct clinical entity, identified as a chronic inflammatory process of the pancreas in which the autoimmune mechanism is involved. Clinically and histologically, AIP has two subsets: type 1 – lymphoplasmatic sclerosing pancreatitis with abundant infiltration of the pancreas and other affected organs with immunoglobulin G4-positive plasma cells, and type 2 – duct centric fibrosis, characterized by granulocyte epithelial lesions in the pancreas without systemic involvement. In the diagnosis of AIP, two diagnostic criterions are used – the HISORt criteria and Asian Diagnostic Criteria. In the differential diagnosis, the pancreatic cancer must be excluded by endosonographically guided pancreatic biopsy. Typical signs of AIP are concomitant disorders in other organs (kidney, liver, biliary tract, salivary glands, colon, retroperitoneum, prostate). Novel clinicopathological entity was proposed as an ‘IgG4-related sclerosing disease’ (IgG4-RSC). Extensive IgG4-positive plasma cells and T lymphocyte infiltration is a common characteristics of this disease. Recently, IgG4-RSC syndrome was extended to a new entity, characterized by IgG4 hypergammaglobulinemia and IgG4-positive plasma cell infiltration, this being considered an expression of a lymphoproliferative disease, ‘IgG4-positive multiorgan lymphoproliferative syndrome’. This syndrome includes Mikulicz’s disease, mediastinal fibrosis, autoimmune hypophysitis, and inflammatory pseudotumor – lung, liver, breast. In the therapy of AIP, steroids constitute first-choice treatment. High response to the corticosteroid therapy is an important diagnostic criterion. In the literature, there are no case-control studies that determine if AIP predisposes to pancreatic cancer. Undoubtedly, AIP is currently a hot topic in pancreatology.

Pancreatic pain@@@Schmerz bei Pankreaserkrankungen

SummaryPain is a common symptom of many diseases. Recently, the pain has been classified and analyzed exactly. Its particular components/types are described to the maximum of their depths and details. That is why each particular pain present in a specific disease (pancreatopathies included) has to be treated according to the presence of the specific type of pain. In diseases of pancreas, there are nociceptive, neuropathic, and inflammatory components of pain participating, frequently. Especially long-lasting, not well-controlled pain sets off the process of neuromodulation. The recent pioneering applications/administrations of various neuromodulatory therapeutic approaches represent the promising discoveries for the treatment of long-term, severe, drug-resistant pain syndromes, including chronic pancreatitis. In this article, we summarized the characteristics of pain, the therapeutic strategy, and algorithms of analgesic treatment (in general and applied for pancreatopathies), including new therapeutic trends and approaches.ZusammenfassungSchmerz ist ein unspezifisches Symptom vieler Erkrankungen. Schmerz kann in seinen Qualitäten und Ursachen näher untersucht und klassifiziert werden. Die spezifischen Schmerzursachen und Schmerzkomponenten können mittlerweile detailliert erfasst werden. Auf Grund dessen muss jede Art von Schmerz bei einer Erkrankung, so auch bei Erkrankungen des Pankreas, spezifisch nach dem jeweiligen Schmerztyp behandelt werden. Bei Pankreaserkrankungen liegen regelmäßig nozizeptive, neuropathische und inflammatorische Schmerzkomponenten vor und spielen zusammen als Schmerzursachen eine Rolle. Langanhaltende und schlecht kontrollierte Schmerzzustände führen zu einer Neuromodulation. Rezente Neuerungen bei der Applikation und im Einsatz von verschiedenen neuromodulatorischen Schmerzmedikamenten stellen neue Therapieansätze dar, die die Hoffnung geben, auch bei schweren, lang anhaltenden und mit konventioneller Schmerztherapie schlecht kontrollierbaren Schmerzsyndromen Erfolge zu erzielen, so auch bei der chronischen Pankreatitis. Im vorliegenden Artikel werden die Schmerzkomponenten, die Therapiestrategien sowie die Algorithmen der Schmerztherapie im allgemeinen und speziell für Pankreaserkrankungen dargestellt. Dies beinhaltet auch neue therapeutische Ansätze und Entwicklungen.