Acute pancreatitis is a common gastrointestinal disease with increasing incidence worldwide. COVID-19 is a potentially life-threatening contagious disease spread throughout the world, caused by severe acute respiratory syndrome coronavirus 2. More severe forms of both diseases exhibit commonalities with dysregulated immune responses resulting in amplified inflammation and susceptibility to infection. Human leucocyte antigen (HLA)-DR, expressed on antigen-presenting cells, acts as an indicator of immune function. Research advances have highlighted the predictive values of monocytic HLA-DR (mHLA-DR) expression for disease severity and infectious complications in both acute pancreatitis and COVID-19 patients. While the regulatory mechanism of altered mHLA-DR expression remains unclear, HLA-DR^−/low monocytic myeloid-derived suppressor cells are potent drivers of immunosuppression and poor outcomes in these diseases. Future studies with mHLA-DR-guided enrollment or targeted immunotherapy are warranted in more severe cases of patients with acute pancreatitis and COVID-19.

Coagulopathy is a critical pathophysiological mechanism of acute pancreatitis (AP), arising from the complex interplay between innate immune, endothelial cells and platelets. Although initially beneficial for the host, uncontrolled and systemic activation of coagulation cascade in AP can lead to thrombotic and hemorrhagic complications, ranging from subclinical abnormalities in coagulation tests to severe clinical manifestations, such as disseminated intravascular coagulation. Initiation of coagulation activation and consequent thrombin generation is caused by expression of tissue factor on activated monocytes and is ineffectually offset by tissue factor pathway inhibitor. At the same time, endothelial-associated anticoagulant pathways, in particular the protein C system, is impaired by pro-inflammatory cytokines. Also, fibrin removal is severely obstructed by inactivation of the endogenous fibrinolytic system, mainly as a result of upregulation of its principal inhibitor, plasminogen activator inhibitor type 1. Finally, increased fibrin generation and impaired break down lead to deposition of (micro) vascular clots, which may contribute to tissue ischemia and ensuing organ dysfunction. Despite the high burden of coagulopathy that have a negative impact on AP patients’ prognosis, there is no effective treatment yet. Although a variety of anticoagulants drugs have been evaluated in clinical trials, their beneficial effects are inconsistent, and they are also characterized by hemorrhagic complications. Future studies are called to unravel the pathophysiologic mechanisms involved in coagulopathy in AP, and to test novel therapeutics block coagulopathy in AP.

Chaiqinchengqi decoction, a traditional Chinese medicine, has shown promising effects in in vitro, animal and preliminary small human studies for acute pancreatitis, but evidence of clinical practice is limited. To investigate whether Chaiqinchengqi decoction could improve clinical outcomes in patients with acute pancreatitis. Prospective, pragmatic, randomized controlled trial. (Chictr.org.cn registration number: ChiCTR2000034325) METHODS: This trial was conducted at West China Hospital of Sichuan University, China. Patients with acute pancreatitis were randomly assigned to receive either Chaiqinchengqi decoction or placebo by oral and rectal enemas in addition to guideline-directed administrations using a 1:1 ratio. The intervention of Chaiqinchengqi and placebo was determined by the grading of acute gastrointestinal injury. Patients were assessed within 24 and 48 hours, and on 3, 5, and 7 days after admission, or organ failure normalized. Survivors were followed up at 1, 3, and 6 months after discharge. Primary outcome was the duration of respiratory failure to 28 days after enrollment. Secondary outcomes included other organ failure, local complications, 6-month all-cause mortality, inflammatory indicators, and related interventions. Among 248 patients enrolled, Chaiqinchengqi decoction shortened the duration of respiratory failure compared with the placebo (median [IQR], 1.0 [0.0 to 5.0] vs 3.0 [1.0-8.0] days; median difference, -1.0; 95% CI, -2.0 to 0.0, P=.001). There were significant differences in the duration of circulatory failure, the incidence of new-onset respiratory and cardiovascular and failure, the incidence of new organ failure, severity, intensive care unit need, pain visual analogue scale, pancreatitis activity scoring system, and EQ-5D-5L. Chaiqinchengqi decoction as an adjunctive therapy significantly reduced the duration of respiratory failure and improved 6-month clinical outcomes of acute pancreatitis in addition to guideline-directed treatments. Further study is needed to elucidate the mechanism of action.

Background: The stress hyperglycemia ratio (SHR) has emerged as a promising biomarker for assessing stress-induced hyperglycemia (SH) but has not been evaluated in patients with acute pancreatitis (AP). This study investigates the role of the SHR in predicting adverse clinical outcomes in patients with AP. Methods: Adult patients with AP who were admitted within 72 h of the onset of abdominal pain were screened in the database. Eligible patients with glycated hemoglobin (HbA1c) and blood glucose were analyzed. The SHR was calculated using admission blood glucose and HbA1c levels. Patients were categorized into four groups: SHR1 (≤1.03), SHR2 (1.04–1.25), SHR3 (1.26–1.46), and SHR4 (≥1.47). The primary outcome was persistent organ failure (POF). The secondary outcomes included acute peripancreatic fluid collection (APFC) and high-dependency unit/intensive care unit (HDU/ICU) admission. Restricted cubic spline (RCS) analysis was used to assess nonlinear associations and identify SHR threshold values. Univariable and multivariable logistic regression models were used to adjust for potential confounders and evaluate the relationship between the SHR and clinical outcomes. Results: A total of 486 patients with AP were included in this study, comprising 85 with POF and 401 without POF. SHR levels and severity were significantly correlated, with the highest quartile in the greatest proportion of severe acute pancreatitis (SAP). Higher SHR levels were significantly associated with an increased risk of POF, APFC, and HDU/ICU admission. RCS analysis revealed a nonlinear relationship between the SHR and APFC (p = 0.009). Based on the RCS and quartile analysis, SHR > 1.25 was identified as the threshold for increased risk. After adjusting for confounders, SHR > 1.25 remained independently associated with higher risks of POF (OR: 2.49, 95% CI: 1.39–4.46, p = 0.002), APFC (OR: 2.85, 95% CI: 1.92–4.24, p < 0.001), and ICU admission (OR: 1.74, 95% CI: 1.12–2.69, p = 0.013). Conclusions: The SHR is independently associated with adverse clinical outcomes in AP, including POF, APFC, and HDU/ICU admission. These findings suggest that the SHR may serve as a valuable biomarker for risk stratification and early intervention in AP management.

Objectives: This study aims to analyze the clinical characteristics of elderly patients with acute pancreatitis (AP) and investigate the effects of age on the clinical outcomes of AP. Methods: Patients aged ≥ 18 years with AP admitted within 72 h from 1 September 2013 to 31 August 2019 were included. Patients were divided into elderly (≥60 years) and non-elderly (<60 years) groups. Clinical data and outcomes were compared. Results: A total of 756 elderly and 4896 non-elderly patients with AP were included. The elderly patients had different etiological distributions and more severe clinical markers and scores. Age was an independent risk factor for mortality [odds ratio (OR): 2.911, 95% CI: 1.801–4.706, p < 0.001], intensive care unit admission (OR: 1.739, 95% CI: 1.126–2.685, p = 0.013), persistent organ failure (OR: 1.623, 95% CI: 1.326–1.987, p < 0.001), multiple organ failure (OR: 1.757, 95% CI: 1.186–2.604, p = 0.005), and infection (OR: 2.451, 95% CI: 1.994–3.013, p < 0.001). Adjusted multiple logistic regression and trend analysis confirmed the risk of the age for the outcomes. The deaths of elderly patients showed a biphasic pattern with peaks in the first and fifth weeks, in contrast to the single peak in the first week in the non-elderly patients. Conclusions: Elderly patients with AP were associated with worse clinical outcomes. It is crucial to devote considerable attention to the optimization of therapeutic approaches to reduce late mortality in this group of patients.