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Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards.
Jabłońska, B, Mrowiec, S
Nutrients. 2021;(5)
Abstract
Severe acute pancreatitis (SAP) leads to numerous inflammatory and nutritional disturbances. All SAP patients are at a high nutritional risk. It has been proven that proper nutrition significantly reduces mortality rate and the incidence of the infectious complications in SAP patients. According to the literature, early (started within 24-48 h) enteral nutrition (EN) is optimal in most patients. EN protects gut barrier function because it decreases gastrointestinal dysmotility secondary to pancreatic inflammation. Currently, the role of parenteral nutrition (PN) in SAP patients is limited to patients in whom EN is not possible or contraindicated. Early versus delayed EN, nasogastric versus nasojejunal tube for EN, EN versus PN in SAP patients and the role of immunonutrition (IN) in SAP patients are discussed in this review.
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Diabetes following acute pancreatitis.
Hart, PA, Bradley, D, Conwell, DL, Dungan, K, Krishna, SG, Wyne, K, Bellin, MD, Yadav, D, Andersen, DK, Serrano, J, et al
The lancet. Gastroenterology & hepatology. 2021;(8):668-675
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Abstract
Diabetes represents a group of diseases involving persistent hyperglycaemia. Exocrine disorders of the pancreas are increasingly recognised to cause or precede the onset of diabetes, which in this context is referred to as pancreatogenic or type 3c diabetes. Diabetes, as a sequela of acute pancreatitis, is observed across the spectrum of severity in acute pancreatitis and can be associated with other clinical complications. The pathophysiology of acute pancreatitis-related diabetes is poorly understood, and observations suggest that it is probably multifactorial. In this Review, we discuss the epidemiology, pathophysiology, and management considerations of diabetes following acute pancreatitis, and highlight knowledge gaps in this topic.
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Life-threatening hypertriglyceridemia-induced pancreatitis related to alectinib successfully treated by plasmapheresis: A review of the literature on metabolic toxicities associated with anaplastic lymphoma kinase inhibitors.
Rao, A, Reddy, A, Dinunno, C, Elali, I
Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners. 2020;(6):1533-1537
Abstract
INTRODUCTION Actionable mutations are tested as standard of care for all new metastatic non-small cell lung cancers. Tumors harboring an anaplastic lymphoma kinase mutation respond to tyrosine kinase inhibitors targeting anaplastic lymphoma kinase pathway. Patients are monitored for common adverse effects, although we occasionally encounter unexpected side effects. CASE REPORT A 52-year-old male presented with a right hilar lung mass, and workup revealed a stage IIIA adenocarcinoma. He underwent treatment with concurrent chemoradiation; however, disease recurred one year later with a right hilar mass and contralateral mediastinal lymphadenopathy, biopsy of which resulted positive for adenocarcinoma. Molecular analysis showed anaplastic lymphoma kinase rearrangement and alectinib was started. Six months into therapy, he presented with hematochezia, nausea, and epigastric pain and was diagnosed with acute pancreatitis. Triglyceride level resulted above the measurable level at >5680mg/dL, thought to be the inciting event of pancreatitis.Management and outcome: Despite treatment with intravenous hydration, insulin infusion, and antibiotics, he decompensated with development of respiratory failure, shock requiring intensive care. Therapeutic plasmapheresis was initiated due to persistently elevated triglyceride. Following the third plasmapheresis, triglyceride level decreased to 359 mg/dL. With aggressive multidisciplinary management, he made a complete recovery. Follow-up imaging studies at three and six months show a stable mass-like abnormality in the right hilum without evidence of disease progression. DISCUSSION Prior to starting alectinib, our patient's triglyceride level was 420 mg/dL. While he consumed alcohol, he had no other traditional risk factor. To our knowledge, this is the first reported case of hypertriglyceridemia-induced acute pancreatitis related to treatment with an anaplastic lymphoma kinase inhibitor.
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Acute Pancreatitis: Exploring Nutrition Implications.
Murphy, AE, Codner, PA
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(5):807-817
Abstract
Diseases of the pancreas vary by type, etiology, pathophysiology, and outcomes. One of the principle therapeutic considerations in all types of pancreatic diseases is nutrition. This review will consider acute pancreatitis (AP). Choice of patient, type and composition of nutrition, and timing of initiation will be discussed as components for achieving the maximum benefits of nutrition therapy in AP. The paradigm of nutrition therapy in AP has shifted to early enteral and/or oral nutrition based on disease severity to help mitigate the underlying inflammatory cascade of events leading to AP, beginning with anatomic and functional intestinal changes. Additionally, newer research investigating the inflammatory changes that instigate, maintain, and propagate AP will be discussed in terms of the nutrition effects on systemic inflammation. Nutrition therapy can mitigate the inflammatory changes in the intestinal tract and help with intestinal motility, bacterial overgrowth and translocation. It can help maintain intestinal bacterial composition and abundance similar to predisease levels. This review will also discuss the changes in the intestinal microbiome and effects of probiotics in AP.
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Hepatobiliary Adverse Events.
Abu-Sbeih, H, Wang, Y
Advances in experimental medicine and biology. 2020;:271-276
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used for multiple cancer types. Hepatotoxicity is a reported adverse event of ICI treatment. It can present as asymptomatic elevation of aspartate transaminase and alanine transaminase or symptomatic hepatitis with fever, malaise, and even death in rare cases. The diagnosis of ICI-induced hepatitis is made after exclusion of other etiologies based on medical history, laboratory evaluation, and imaging and histological findings. Treatment of ICI-induced hepatitis consists of ICI discontinuation and immunosuppression in severe cases. Pancreatic injury as asymptomatic lipase elevation or acute pancreatitis-like disease with abdominal pain and evidence on imaging has been documented as a toxicity of ICI therapy. Appropriate treatment of pancreatitis still needs further investigation. Few cases, reports, and series documented cholecystitis and cholangitis as possible adverse events related to ICI therapy as well.
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Nutrition Management in Acute Pancreatitis.
Ramanathan, M, Aadam, AA
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;:S7-S12
Abstract
Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.
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[An underestimate iatrogenic effect of antithyroid drugs: Acute pancreatitis].
Ben Hamou, A, Banu, I, Dupuy, O
Presse medicale (Paris, France : 1983). 2019;(11 Pt 1):1334-1336
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Nutrition Interventions in Pediatric Pancreatitis: Guidelines We Can Trust.
Theodoridis, X, Grammatikopoulou, MG, Petalidou, A, Stamouli, EM, Fotiadou, I, Gkiouras, K, Bogdanos, DP, Dardavessis, T
Journal of pediatric gastroenterology and nutrition. 2019;(1):120-125
Abstract
OBJECTIVE Despite the fact that pediatric pancreatitis is an uncommon disease, its prevalence has increased in recent years. Nevertheless, until 4 years ago, the lack of nutritional guidelines for pediatric pancreatitis was evident, with all recommendations being based on clinical practice guidelines (CPGs) for adults. The aim of the present study was to review and critically appraise guidelines for the medical nutrition therapy (MNT) of pediatric pancreatitis. METHODS A comprehensive search was performed in electronic databases (PubMed, Scopus, National Institute for Health and Care Excellence), the International Guidelines Network, BMJ best practice, and the Scottish Intercollegiate Guidelines Network to identify CPGs on the MNT of pediatric pancreatitis. The validated AGREE II tool was used for guidelines appraisal by a team of 3 independent multidisciplinary reviewers. RESULTS A total of 4 CPGs were retrieved with pediatric pancreatitis MNT information. Out of the 4 advising bodies in total, the joint society paper published by the ESPGHAN/NASPGHAN received the highest score in almost all domains, whereas the Belgian consensus obtained the lowest score in all domains but stakeholder involvement, and was not recommended by 2 out of 3 reviewers. CONCLUSIONS Pediatric pancreatitis guidelines appear heterogenous in quality, rigour, and transparency. Our study points out existing gaps and biases in the CPGs, and delineates the need for improving the domains identified as being of low-quality.
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Post-pancreatitis diabetes mellitus: towards understanding the role of gastrointestinal motility.
Gold-Smith, FD, Chand, SK, Petrov, MS
Minerva gastroenterologica e dietologica. 2018;(4):363-375
Abstract
Post-pancreatitis diabetes mellitus (PPDM) is a sub-type of diabetes of the exocrine pancreas that develops after acute or chronic inflammation of the pancreas. While pro-inflammatory milieu, glucose metabolism, and lipid metabolism in PPDM have been investigated, little is known about gastrointestinal function in the post-pancreatitis setting. This article overviews studies on epidemiology and impact of gastroparesis in the setting of type 1 and type 2 diabetes, with a view to estimating the possible burden of gastrointestinal dysfunction in PPDM. Further, the usefulness of quantifying gastrointestinal dysmotility is discussed. The gastroparesis cardinal symptom index has emerged as a standardized gastrointestinal dysmotility endpoint and its use in individuals after pancreatitis is justified.
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EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis.
Párniczky, A, Abu-El-Haija, M, Husain, S, Lowe, M, Oracz, G, Sahin-Tóth, M, Szabó, FK, Uc, A, Wilschanski, M, Witt, H, et al
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2018;(2):146-160
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Abstract
BACKGROUND Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has increased, it is now 3.6-13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population. METHODS Pediatric Pancreatitis was divided into three main clinical categories: acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Fifteen relevant topics (acute pancreatitis: diagnosis; etiology; prognosis; imaging; complications; therapy; biliary tract management; acute recurrent pancreatitis: diagnosis; chronic pancreatitis: diagnosis, etiology, treatment, imaging, intervention, pain, complications; enzyme replacement) were defined. Ten experts from the USA and Europe reviewed and summarized the available literature. Evidence was classified according to the GRADE classification system. RESULTS Within fifteen topics, forty-seven relevant clinical questions were defined. The draft of the updated guideline was presented and discussed at the consensus meeting held during the 49th Meeting of European Pancreatic Club, in Budapest, on July 1, 2017. CONCLUSIONS These evidence-based guidelines provides the current state of the art of the diagnosis and management of pediatric pancreatitis.