COVID-19 infection initially presented by interstitial edematous pancreatitis and acute peri-pancreatic collection; the first CT case report in Egypt

Background The extra-pulmonary computed tomography (CT) findings of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 2019 (COVID-19) have been described in the literature, including the neurologic, cardiac, and abdominal manifestations. Ischemic and inflammatory bowel changes were the most frequent abdominal CT findings. Acute pancreatitis was seldom found all over the world outside of China and described in case reports, but not in Egypt. Case presentation A 44-years-old female patient presented with severe abdominal pain, vomiting, and mild fever for six days. No respiratory symptoms were encountered till the time of the radiological investigation. Abdominal CT examination revealed interstitial edematous pancreatitis with acute peri-pancreatic fluid collection according to the revised Atlanta classification. No pancreatic necrosis or vascular complications were depicted. Secondary pyloro-duodenitis was noticed. The modified Balthazar CT-severity index was moderate (6/10). Basal chest scans showed bilateral variable-sized bronchocentric and sub-pleural consolidative pneumonic patches with mild bilateral pleural effusion. The patient was admitted to the intensive-care unit (ICU) for two weeks. The serum amylase and lipase titers were elevated and the polymerase chain reaction (PCR) test for COVID-19 was positive. She received pancreatic, circulatory, and pulmonary medical support, then she was discharged after stabilization of her condition. Conclusion The authors provided this case report for the association between COVID-19 infection and acute pancreatitis, which is mostly the first in Egypt. It documented their Egyptian experience to be added to the international literature. It radiologically described their chest and abdominal CT findings in detail using the COVID-19 Reporting and Data System (CO-RADS) and the revised Atlanta classification with modified Balthazar CT-severity index (CTSI). This could eventually enrich the radiological point of view in addition to the previously published clinical case reports.

Atlanta Classification for Acute Pancreatitis- A Study Protocol

Background: Acute pancreatitis is one of the most common abdominal pathologies having variable outcome ranging from self limiting abdominal pain to high mortality and morbidity due to organ failure, over the past five decades, various classification systems have emerged to classify pancreatitis according to its severity , and the associated complications have emerged to classify acute pancreatitis and its various complications, such as Apache Scoring , Ct Severity , Modified Ct Severity ,Ransen and Atlanta Classification. Objectives: We in our study will be classifying patients suffering from acute pancreatitis according to the revised Atlanta classification to divide them into interstitial edematous pancreatitis and necrotizing pancreatitis. The local complications will be classified according to CT imaging findings into acute necrotic collection, psuedocyst, acute necrotic collection and walled of necrosis. Organ failure will be assessed according to modified marshal scoring system into transient or persistent organ failure. Methodology: We will be carrying forward our study on Siemens 16 slice computer tomography machine over a sample of 140 patients coming to the outpatient department of our hospital which will be followed by a routine clinical follow up of the patient to find out their prognosis. Results: Will be tabulated at the end of the study using SPSS version 26 software. Conclusion: The revised Atlanta classification for acute pancreatitis, in conjunction with the Modified Marshall Scoring System for organ failure, if found useful, in our series in improving the prognosis of the patients, then it can be incorporated in management.

Necroptosis protects against exacerbation of acute pancreatitis

The sensing of various extrinsic stimuli triggers the receptor-interacting protein kinase-3 (RIPK3)-mediated signaling pathway, which leads to mixed-lineage kinase-like (MLKL) phosphorylation followed by necroptosis. Although necroptosis is a form of cell death and is involved in inflammatory conditions, the roles of necroptosis in acute pancreatitis (AP) remain unclear. In the current study, we administered caerulein to Ripk3- or Mlkl-deficient mice (Ripk3−/− or Mlkl−/− mice, respectively) and assessed the roles of necroptosis in AP. We found that Ripk3−/− mice had significantly more severe pancreatic edema and inflammation associated with macrophage and neutrophil infiltration than control mice. Consistently, Mlkl−/− mice were more susceptible to caerulein-induced AP, which occurred in a time- and dose-dependent manner, than control mice. Mlkl−/− mice exhibit weight loss, edematous pancreatitis, necrotizing pancreatitis, and acinar cell dedifferentiation in response to tissue damage. Genetic deletion of Mlkl resulted in downregulation of the antiapoptotic genes Bclxl and Cflar in association with increases in the numbers of apoptotic cells, as detected by TUNEL assay. These findings suggest that RIPK3 and MLKL-mediated necroptosis exerts protective effects in AP and caution against the use of necroptosis inhibitors for AP treatment.

Joint contribution of alcohol abuse and the rs6580502 polymorphism of the SPINK1 gene to the risk of acute alcoholic pancreatitis

Основным фактором риска развития острого алкогольного панкреатита (ОАП) является злоупотребление алкоголем. Алкоголь инициирует экзокринную гиперсекрецию поджелудочной железы, создает предпосылки для повышения давления в протоках. Энзимы проникают в паренхиму, активируют протеолитические ферменты и вызывают аутолиз клеток поджелудочной железы. При избыточном накоплении трипсина в тканях начинается переваривание тканей железы собственными ферментами. SPINK1 - панкреатический секреторный ингибитор трипсина - препятствует преждевременной активации зимогенов. Цель - определить совместный вклад полиморфного локуса rs6580502 гена SPINK1 и злоупотребления алкоголем в развитие острого панкреатита и его осложнений. Образцы ДНК получены от 471 неродственного больного острым небилиарным панкреатитом и 573 неродственных индивидов без заболеваний желудочно-кишечного тракта. Генотипирование выполнено методом ПЦР с дискриминацией аллелей с помощью TaqMan-зондов. Для оценки ассоциаций аллелей и генотипов с риском развития заболевания использовали критерий χ2 и отношение шансов (OR) с 95% доверительными интервалами (CI). Статистический анализ осуществлялся с использованием программы Statistica 6.0 (StatSoft, США). В ходе исследования обнаружена ассоциация генотипа ТТ rs6580502 гена SPINK1 с повышенным риском развития ОАП (corOR (95% CI)= 1,69 (1,22-2,33); р=0,0015R). У носителей генотипа ТТ риск развития ОАП повышали такие факторы риска, как частота употребления алкоголя более 2 раз в неделю (corOR (95% CI) = 1,66 (1,08-2,57); р=0,02R) и объем употребления алкоголя более 200 г в неделю (corOR (95% CI) = 6,04 (1,81-20,17); р= 0,001R). Также была выявлена ассоциация генотипа ТТ с повышенным риском развития отечного панкреатита (corOR (95% CI)= 2.10 (1.44-3.05); p= 1×10-4 R). The main risk factor for the acute non-biliary pancreatitis is alcohol abuse. Alcohol initiates exocrine hypersecretion of the pancreas, creates the prerequisites for increasing pressure in the ducts. Enzymes activate proteolytic enzymes and cause autolysis of pancreatic cells. With an excessive accumulation of trypsin in the tissues, the digestion of the tissues of the gland by its own enzymes begins. SPINK1, a pancreatic secretory trypsin inhibitor, prevents premature activation of zymogens. Aim: to determine the contribution of the rs6580502 polymorphism of the SPINK1 gene and alcohol abuse in the development of acute pancreatitis and its complications. DNA samples obtained from 471 unrelated patients with acute non-biliary pancreatitis and 573 unrelated individuals without gastrointestinal diseases. Genotyping was performed using the PCR method with discrimination of alleles using TaqMan probes. The χ2 criterion and the odds ratio (OR) with 95% confidence intervals (CI) were used to assess the associations of alleles and genotypes of genes with the risk of developing the disease. Statistical analysis was carried out using the Statistica 6.0 software (StatSoft, USA). We found an association of the T/T SPINK1 rs6580502 genotype with an increased risk of developing acute non-biliary pancreatitis (corOR (95% CI)= 1.69 (1.22-2.33); p=0,0015R). In carriers of the TT genotype, the risk of developing SNP was increased by such risk factors as the frequency of drinking more than 2 times per week (corOR (95% CI)= 1,66(1,08-2,57); p=0,02R) and the volume of alcohol consumption more than 200 grams per week (corOR (95% CI)= 6,04(1,81-20,17); p= 0,001R). An association of the T/T genotype with an increased risk of developing edematous pancreatitis was also revealed (corOR (95% CI)= 2.10 (1.44-3.05); Р= 1×10-4 R).

Acute pancreatitis after the removal of a hyperplastic duodenal polyp: a case report

A 59-year-old patient underwent the duodenal endoscopic mucosal resection of a hyperplastic polyp. Four hours after the procedure she developed severe epigastric pain. Laboratory and imaging results were consistent with mild acute edematous pancreatitis. After several days of dietary therapy and intravenous crystalloid fluids the patient recovered, and 1 month later was asymptomatic and had no signs of pancreatic inflammation. This case illustrates a rare but clinically important complication of therapeutic upper endoscopy, which may be attributable to thermal injury of the duodenal wall and the adjacent pancreas. It also underscores the importance of the close follow up of patients who undergo invasive endoscopic procedures and the need for additional preventive measures to be taken when resecting duodenal lesions.

A study of interventions and their outcome in the management of acute pancreatitis

Background: Acute pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it, and the mortality attendant upon it, all render it the most formidable of catastrophes. Aim of the study is to evaluate the treatment outcome in acute pancreatitis.Methods: All the patients who underwent surgery for chronic pancreatitis were included in the study. initial APACHE II score at admission and CT severity index was evaluated.Results: Edematous pancreatitis accounts for 80–90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10–20% of acute pancreatitis and the mortality rate is reported to be 14-25%. Alcohol (45.8%) was the most common causes of acute severe pancreatitis in this study. Males were predominately affected (Male: Female = 29:5). Complication rate or morbidity is 50%. The initial APACHE II score at admission and CT severity index in the first scan were high in patients who underwent necrosectomy and the patients who died. The overall mortality in this study was 30.6%.Conclusions: In conclusion, one reason attributed to high mortality was due to the subgroup of patients who underwent PCD alone and failed to show any change in the recovery nor deterioration and lead to gross nutritional depletion and death, secondly those patients who underwent step up approach and ultimately needed surgery have more aggressive disease evidenced by high APACHE II score, CT severity index and % of necrosis.

Confocal laser endomicroscopy in the diagnosis of extrahepatic bile duct diseases

Aim. To evaluate information content of confocal laser endomicroscopy with targeted biopsy in verifying etiology of extrahepatic bile duct strictures.Material and methods. There were 28 patients with extrahepatic bile duct strictures who underwent retrograde intervention with confocal laser endomicroscopy and targeted biopsy. Data of confocal laser endomicroscopy and biopsy were compared with final postoperative and histological diagnosis. Follow-up within 1–4 years after endoscopic treatment was also considered.Results. Diagnostic sensitivity, specificity and overall accuracy of the method in differential diagnosis of common bile duct strictures were 91.7%, 93.7% and 92.8%, respectively. Complication (acute edematous pancreatitis) occurred in 1 (3.6%) case.Conclusion. Confocal laser endomicroscopy is new effective method for in vivo microscopic assessment of mucous membrane. Despite technical complexity, the method is not associated with advanced morbidity and, accordingly, has no additional contraindications in comparison with ERCP.

Dynamics of changes in the immune system and antioxidant protection in the treatment of acute pancreatitis

The aim of the work was to study the dynamics of changes in the immune system indices and antioxidant protection when fluoroquinolones are included in the treatment regimen for acute edematous pancreatitis. The study included 86 patients with a diagnosis of acute edematous pancreatitis. Group I (n=40) consisted of patients who received treatment according to national and local standards and protocols, group II (n=46) — patients who additionally received fluoroquinolones as part of a comprehensive treatment. The control group consisted of 48 conditionally healthy people in whom laboratory and instrumental diagnostics were carried out similarly to those in patients with acute pancreatitis. According to the purpose and objectives of the study, the state of the immune system and the antioxidant defense system was studied. In patients with acute pancreatitis, changes in the indicators of the immune status were revealed, manifested by the formation of a secondary immunodeficiency with the addition of an autoimmune component. The traditional scheme of pharmacotherapy of acute pancreatitis without the use of antibiotics made it possible to partially correct the indicators of immune status. The use of ciprofloxacin in the complex pharmacotherapy of acute pancreatitis contributed to the normalization of the studied parameters. Thus, the use of fluoroquinolones in the complex pharmacotherapy of acute pancreatitis made it possible to effectively normalize the state of the immune system, cytokine and antioxidant statuses.

THE PARAMETERS OF LIVER FUNCTIONAL STATE AS A RISK FACTOR OF EDEMATOUS PANCREATITIS DEVELOPMENT PROVIDING OF GENETIC DETERMINATION OF IL-4 PRODUCTION

Introduction: One of the main pathophysiological mechanisms of acute pancreatitis development is the damage of pancreas cells and hepatocytes with enzymes activation. Recently, a powerful mechanism of the immune system involvement in the acute pancreatitis pathogenesis, in particular, from the position of genes polymorphism influence attracts more attention. The aim: To study the parameters of liver functional state as risk factors for the development of edematous pancreatitis under the conditions of genetic determination of IL-4 production. Materials and methods: The study involved 101 patients with acute and the exacerbation of chronic pancreatitis in whom the polymorphic variants of gene IL-4 (C-590T), the activity of ALT, AST, GGTP, LDG and bilirubin fractions levels were determined. Results: Among the patients with T-allele of IL-4 gene was more commonly encountered the excess of the activity of AST and ALT standarts than those with CC-genotype - by 27.94% and 24.33% respectively. The increase of the GGTP concentration was recorded in 79.21% of patients. The serum GGTP level was significantly higher in the TT-genotype owners than in those with C-allele. Hyperbilirubinemia by the total bilirubin, indirect and direct fractions was diagnosed more often in TT-genotype carriers than in CC-homozygotes. Conclusions: The dysfunction of hepatopancreatobiliary system is more significant in the TT-genotype carriers of IL-4 gene by the AST, ALT, bilirubin and its fractions high levels, however, were found to be risk factors the high levels of total bilirubin and its direct fraction.