Introduction Acute pancreatitis (AP) is a potentially severe or fatal gastrointestinal disease. Obesity is a major risk factor for chronic comorbidities and for a worse outcome in acute inflammatory conditions. We aimed to investigate the characteristics and role of the degree of obesity in the course and outcome of AP. Methods In total, 2244 AP cases from 13 countries and 29 centers of the Acute Pancreatitis Registry run by the Hungarian Pancreatic Study Group were included in our analysis. Patient groups were formed based on body mass index (BMI) categories according to the World Health Organization definitions. Anamnestic, admission, and outcome parameters were analyzed. We used logistic regression and multivariable logistic regression to model the relationship between BMI and AP outcomes. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Results In our cohort, 2.8% of patients were underweight, 30.0% normal, 35.0% overweight, and 20.0%, 8.2%, and 3.7% were in the obesity class I, II, and III groups.Examining the graded association in a multivariable logistic regression model, we found that the odds of organ failure increase with the degree of obesity (obesity class I: OR = 2.12, CI:1.29-3.46, p = 0.003; obesity class II: OR = 2.57, CI:1.40-4.71, p = 0.002; obesity class III: OR = 2.71, CI:1.25-5.89, p = 0.012). The three obesity groups had higher odds for severe AP as well (OR = 3.16, CI:1.71-5.83, p < 0.001; OR = 3.98, CI:1.95-8.15, p < 0.001; OR = 2.80, CI:1.05-7.48, p = 0.040, respectively). Conclusion Obesity dose-dependently elevates the odds of pre-existing comorbidities and complications. Gradual weight loss may also have a positive effect and the impact of patient education should be investigated.

Background: Hypercalcemia is a rare etiology of acute pancreatitis; only a few cases have been reported in the literature, and the severity of hypercalcemia-induced AP is unknown. We aimed to assess the occurrence and severity of hypercalcemia-induced AP and compare it with the clinical characteristics of AP caused by other etiological factors. Methods: We collected data from patients from the Hungarian Acute Pancreatitis Registry who had AP, a serum calcium level above 2.6 mmol/L, and no other AP etiology. AP patients with etiologies other than hypercalcemia served as control. Results: A total of 1.20% of our AP patients (16/1328) had a clear hypercalcemic etiology, 5.05% (67/1328) had a mixed etiology, and 1245 patients were in the control group. Severe AP, organ failure, and renal failure were significantly more common in patients with hypercalcemia-induced AP than in the control or the mixed etiology groups. Heart failure was significantly more frequent in the clear hypercalcemia-induced group than in patients with normal serum calcium AP. Respiratory failure was significantly more common in the clear hypercalcemia-induced AP group than in the mixed etiology-induced group. There was no significant difference in other analyzed parameters. The outcome of AP was not associated with the severity of hypercalcemia within the hypercalcemic group. Conclusions: Compared with AP of different etiologies, hypercalcemia-induced AP is more likely to develop into severe AP and organ failure (heart and kidneys).

There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients’ care.

AbstractIntroductionNon‐alcoholic fatty liver disease (NAFLD) is a proven risk factor for acute pancreatitis (AP). However, NAFLD has recently been redefined as metabolic‐associated fatty liver disease (MAFLD). In this post hoc analysis, we quantified the effect of MAFLD on the outcomes of AP.MethodsWe identified our patients from the multicentric, prospective International Acute Pancreatitis Registry of the Hungarian Pancreatic Study Group. Next, we compared AP patients with and without MAFLD and the individual components of MAFLD regarding in‐hospital mortality and AP severity based on the revised Atlanta classification. Lastly, we calculated odds ratios (ORs) with 95% confidence intervals (CIs) using multivariate logistic regression analysis.ResultsMAFLD had a high prevalence in AP, 39% (801/2053). MAFLD increased the odds of moderate‐to‐severe AP (OR = 1.43, CI: 1.09–1.89). However, the odds of in‐hospital mortality (OR = 0.89, CI: 0.42–1.89) and severe AP (OR = 1.70, CI: 0.97–3.01) were not higher in the MAFLD group. Out of the three diagnostic criteria of MAFLD, the highest odds of severe AP was in the group based on metabolic risk abnormalities (OR = 2.68, CI: 1.39–5.09). In addition, the presence of one, two, and three diagnostic criteria dose‐dependently increased the odds of moderate‐to‐severe AP (OR = 1.23, CI: 0.88–1.70, OR = 1.38, CI: 0.93–2.04, and OR = 3.04, CI: 1.63–5.70, respectively) and severe AP (OR = 1.13, CI: 0.54–2.27, OR = 2.08, CI: 0.97–4.35, and OR = 4.76, CI: 1.50–15.4, respectively). Furthermore, in patients with alcohol abuse and aged ≥60 years, the effect of MAFLD became insignificant.ConclusionsMAFLD is associated with AP severity, which varies based on the components of its diagnostic criteria. Furthermore, MAFLD shows a dose‐dependent effect on the outcomes of AP.

Pancreatic necrosis is a consistent prognostic factor in acute pancreatitis (AP). However, the clinical scores currently in use are either too complicated or require data that are unavailable on admission or lack sufficient predictive value. We therefore aimed to develop a tool to aid in necrosis prediction. The XGBoost machine learning algorithm processed data from 2387 patients with AP. The confidence of the model was estimated by a bootstrapping method and interpreted via the 10th and the 90th percentiles of the prediction scores. Shapley Additive exPlanations (SHAP) values were calculated to quantify the contribution of each variable provided. Finally, the model was implemented as an online application using the Streamlit Python-based framework. The XGBoost classifier provided an AUC value of 0.757. Glucose, C-reactive protein, alkaline phosphatase, gender and total white blood cell count have the most impact on prediction based on the SHAP values. The relationship between the size of the training dataset and model performance shows that prediction performance can be improved. This study combines necrosis prediction and artificial intelligence. The predictive potential of this model is comparable to the current clinical scoring systems and has several advantages over them.

The reaction of (dpp-bian)Ga–Zn(dpp-bian) (dpp-bian is 1,2-bis[(2,6-diisopropylphenyl)imino]acenaphthene) with 1,3-di(4-pyridyl)propane results in 1D coordination polymer [(dpp-bian)Ga–Zn(dpp-bian)(μ2-1,3-Py2(CH2)3)]n with the retained Ga–Zn bond. In contrast, the coordination of 1,3-di(4-pyridyl)propane to Zn atoms in the (dpp-bian)Zn–Zn(dpp-bian) complex induces the cleavage of the Zn–Zn bond which is accompanied by reduction of dpp-bian radical anions to dianions. The reaction product represents 1D coordination polymer [{(dpp-bian)Zn}(μ2-1,3-Py2(CH2)3)]n.

Chronic pancreatitis (CP) is an end-stage disease with no specific therapy; therefore, an early diagnosis is of crucial importance. In this study, data from 1315 and 318 patients were analysed from acute pancreatitis (AP) and CP registries, respectively. The population from the AP registry was divided into AP (n = 983), recurrent AP (RAP, n = 270) and CP (n = 62) groups. The prevalence of CP in combination with AP, RAP2, RAP3, RAP4 and RAP5 + was 0%, 1%, 16%, 50% and 47%, respectively, suggesting that three or more episodes of AP is a strong risk factor for CP. Laboratory, imaging and clinical biomarkers highlighted that patients with RAP3 + do not show a significant difference between RAPs and CP. Data from CP registries showed 98% of patients had at least one AP and the average number of episodes was four. We mimicked the human RAPs in a mouse model and found that three or more episodes of AP cause early chronic-like morphological changes in the pancreas. We concluded that three or more attacks of AP with no morphological changes to the pancreas could be considered as early CP (ECP).The new diagnostic criteria for ECP allow the majority of CP patients to be diagnosed earlier. They can be used in hospitals with no additional costs in healthcare.

The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Data from 2461 patients were extracted from the international, prospective, multicentre AP registry operated by the Hungarian Pancreatic Study Group. Data from patients with albumin measurement in the first 48 h (n = 1149) and anytime during hospitalization (n = 1272) were analysed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. The prevalence of hypoalbuminemia (< 35 g/L) was 19% on admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on admission was poor for severity and mortality. Severe hypoalbuminemia (< 25 g/L) represented an independent risk factor for severity (OR 48.761; CI 25.276–98.908) and mortality (OR 16.83; CI 8.32–35.13). Albumin loss during AP was strongly associated with severity (p < 0.001) and mortality (p = 0.002). Hypoalbuminemia represents an independent risk factor for severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure and length of stay.

Background: Metabolic risk factors, such as obesity, hypertension, and hyperlipidemia are independent risk factors for the development of various complications in acute pancreatitis (AP). Hypertriglyceridemia dose-dependently elicits pancreatotoxicity and worsens the outcomes of AP. The role of hyperglycemia, as a toxic metabolic factor in the clinical course of AP, has not been examined yet. Methods: We analyzed a prospective, international cohort of 2250 AP patients, examining associations between (1) glycosylated hemoglobin (HbA1c), (2) on-admission glucose, (3) peak in-hospital glucose and clinically important outcomes (mortality, severity, complications, length of hospitalization (LOH), maximal C-reactive protein (CRP)). We conducted a binary logistic regression accounting for age, gender, etiology, diabetes, and our examined variables. Receiver Operating Characteristic Curve (ROC) was applied to detect the diagnostic accuracy of the three variables. Results: Both on-admission and peak serum glucose are independently associated with AP severity and mortality, accounting for age, gender, known diabetes and AP etiology. They show a dose-dependent association with severity (p < 0.001 in both), mortality (p < 0.001), LOH (p < 0.001), maximal CRP (p < 0.001), systemic (p < 0.001) and local complications (p < 0.001). Patients with peak glucose >7 mmol/l had a 15 times higher odds for severe AP and a five times higher odds for mortality. We found a trend of increasing HbA1c with increasing LOH (p < 0.001), severity and local complications. Conclusions: On-admission and peak in-hospital glucose are independently and dose-dependently associated with increasing AP severity and mortality. In-hospital laboratory control of glucose and adequate treatment of hyperglycemia are crucial in the management of AP. (c) 2021 Published by Elsevier B.V. on behalf of IAP and EPC.

Background: Pseudocysts being the most frequent local complications of acute pancreatitis (AP) have substantial effect on the disease course, hospitalization and quality of life of the patient. Our study aimed to understand the effects of pre-existing (OLD-P) and newly developed (NEW-P) pseudocysts on AP. Methods: Data were extracted from the Acute Pancreatitis Registry organized by the Hungarian Pancreatic Study Group (HPSG). 2275 of 2461 patients had uploaded information concerning pancreatic morphology assessed by imaging technique. Patients were divided into "no pseudocyst" (NO-P) group, "old pseudocyst" (OLD-P) group, or "newly developed pseudocyst" (NEW-P) groups. Results: The median time of new pseudocyst development was nine days from hospital admission and eleven days from the beginning of the abdominal pain. More NEW-P cases were severe (15.9% vs 4.7% in the NO-P group p < 0.001), with longer length of hospitalization (LoH) (median: 14 days versus 8 days, p < 0.001), and were associated with several changed laboratory parameters. OLD-P was associated with male gender (72.2% vs. 56.1%, p = 0.0014), alcoholic etiology (35.2% vs. 19.8% in the NO-P group), longer hospitalization (median: 10 days, p < 0.001), a previous episode of AP (p < 0.001), pre-existing diagnosis of chronic pancreatitis (CP) (p < 0.001), current smoking (p < 0.001), and increased alcohol consumption (unit/week) (p = 0.014). Conclusion: Most of the new pseudocysts develop within two weeks. Newly developing pseudocysts are associated with a more severe disease course and increased length of hospitalization. Pre-existing pseudocysts are associated with higher alcohol consumption and smoking. Because CP is more frequently associated with a pre-existing pseudocyst, these patients need closer attention after AP. (c) 2021 The Authors. Published by Elsevier B.V. on behalf of IAP and EPC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Pain is the most common symptom in acute pancreatitis (AP) and is among the diagnostic criteria. Therefore, we aimed to characterize acute abdominal pain in AP.

Introduction The incidence and medical costs of acute pancreatitis (AP) are on the rise, and severe cases still have a 30% mortality rate. We aimed to evaluate hypoalbuminemia as a risk factor and the prognostic value of human serum albumin in AP. Methods Data of 2461 patients were extracted from the international, prospective, multicenter AP registry of the Hungarian Pancreatic Study Group. Data of patients with albumin measurement in the first 48 hours (n=1149) and anytime during hospitalization (n=1272) was analyzed. Multivariate binary logistic regression and Receiver Operator Characteristic curve analysis were used. Results The prevalence of hypoalbuminemia (<35g/L) was 19% on-admission and 35.7% during hospitalization. Hypoalbuminemia dose-dependently increased the risk of severity, mortality, local complications, and organ failure and is associated with longer hospital stay. The predictive value of hypoalbuminemia on-admission was poor for severity and mortality. Severe hypoalbuminemia (<25 g/L) was an independent risk factor for severity (OR: 48.761; CI:25.276-98.908) and mortality (OR:16.83; CI: 8.32-35.13). Albumin loss during AP was strongly associated with severity (p<0.001) and mortality (p=0.002). Conclusion Hypoalbuminemia is an independent risk factor of severity and mortality in AP, and it shows a dose-dependent relationship with local complications, organ failure, and length of stay.

Background: Acute pancreatitis (AP) is a life-threatening disease. We aimed to explore the prognostic relevance of renal function based on estimated glomerular filtration rate (eGFR).Methods: A prospective registry of AP patients was established by the Hungarian Pancreatic Study Group. Data of 1,224 consecutive patients were collected between 2012 and 2017. Patients were divided into 3 groups according to their eGFR measured within 24 h of hospitalization: normal renal function: >90 mL/min, mild to moderate renal functional impairment: 30–90 mL/min and severe renal dysfunction: <30 mL/min. Associations of eGFR with outcome (survival, length of hospitalization, AP severity, blood glucose), inflammatory markers (erythrocyte sedimentation rate, white blood cell count), anemia and organ failure (heart, kidney, liver) were analyzed.Results: Death, longer hospitalization and severe AP, but not the cause of AP, were significantly associated with lower eGFR. The inflammatory markers (CRP, WBC count) but not anemia (Hb, Htk) were closely associated with severe renal dysfunction. Renal function was associated with heart and renal failure but not with other complications of AP such as respiratory failure, local pancreatic complications, diabetes or peptic ulcer. eGFR was not associated with liver damage (ALAT, γ-GT) or liver function (serum bilirubin) although biliary complications, alcohol and metabolic syndrome were the most common etiologies of AP.Conclusions: Our study suggests a useful prognostic value of initial eGFR in AP patients. Even mild eGFR reduction predicted mortality, severity of AP and the length of hospitalization. Thus, precise evaluation of renal function should be considered for assessing AP severity and outcome.

Background: Disturbance of consciousness (DOC) may develop in acute pancreatitis (AP). In clinical practice, it is known that DOC may worsen the patient's condition, but we have no exact data on how DOC affects the outcome of AP. Methods: From the Hungarian Pancreatic Study Groups' AP registry, 1220 prospectively collected cases were analyzed, which contained exact data on DOC, included patients with confusion, delirium, convulsion, and alcohol withdrawal, answering a post hoc defined research question. Patients were separated to Non-DOC and DOC, whereas DOC was further divided into non-alcohol related DOC (Non-ALC DOC) and ALC DOC groups. For statistical analysis, independent sample t-test, Mann-Whitney, Chi-squared, or Fisher exact test were used. Results: From the 1220 patients, 47 (3.9%) developed DOC, 23 (48.9%) cases were ALC DOC vs. 24 (51.1%) Non-ALC DOC. Analysis between the DOC and Non-DOC groups showed a higher incidence of severe AP (19.2% vs. 5.3%, p < 0.001), higher mortality (14.9% vs. 1.7%, p < 0.001), and a longer length of hospitalization (LOH) (Me = 11; IQR: 8-17 days vs. Me = 9; IQR: 6-13 days, p = 0.049) respectively. Patients with ALC DOC developed more frequently moderate AP vs. Non-ALC DOC (43.5% vs. 12.5%), while the incidence of severe AP was higher in Non-ALC vs. ALC DOC group (33.3% vs. 4.4%) (p < 0.001). LOH showed a tendency to be longer in Non-ALC DOC compared to ALC DOC, respectively (Me:13; IQR:7-20 days vs. Me:9.5; IQR:8-15.5 days, p = 0.119). Conclusion: DOC during AP is associated with a higher rate of moderate and severe AP and increases the risk of mortality. (c) 2020 IAP and EPC. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background: Acid suppressing drugs (ASD) are generally used in acute pancreatitis (AP); however, large cohorts are not available to understand their efficiency and safety. Therefore, our aims were to evaluate the association between the administration of ASDs, the outcome of AP, the frequency of gastrointestinal (GI) bleeding and GI infection in patients with AP. Methods: We initiated an international survey and performed retrospective data analysis on AP patients hospitalized between January 2013 and December 2018. Results: Data of 17,422 adult patients with AP were collected from 59 centers of 23 countries. We found that 23.3% of patients received ASDs before and 86.6% during the course of AP. ASDs were prescribed to 57.6% of patients at discharge. ASD administration was associated with more severe AP and higher mortality. GI bleeding was reported in 4.7% of patients, and it was associated with pancreatitis severity, mortality and ASD therapy. Stool culture test was performed in 6.3% of the patients with 28.4% positive results. Clostridium difficile was the cause of GI infection in 60.5% of cases. Among the patients with GI infections, 28.9% received ASDs, whereas 24.1% were without any acid suppression treatment. GI infection was associated with more severe pancreatitis and higher mortality. Conclusions: Although ASD therapy is widely used, it is unlikely to have beneficial effects either on the outcome of AP or on the prevention of GI bleeding during AP. Therefore, ASD therapy should be substantially decreased in the therapeutic management of AP. (C) 2020 IAP and EPC. Published by Elsevier B.V.