Introduction

The Revision of the Atlanta Classification (RAC) defines severe acute pancreatitis (AP) by the presence of persistent organ failure (OF), limited to respiratory, renal, or cardiovascular systems, this being associated with a high mortality rate. Whether gastrointestinal bleeding (GIB) and impaired mental status (IMS) should be considered as OF remains unclear. We aimed to assess the association of GIB and IMS with mortality and other outcomes.

Aims & Methods

We performed a retrospective analysis of a prospective database including 1,612 AP patients. GIB was defined as bleeding >500 mL. IMS was defined as a Glasgow score ≤14 at baseline. Multivariate logistic regression models were used to assess associations with mortality, controlling for comorbidity and RAC- defined OF. Two models were used: one including all OF (any duration), and another including only persistent OF.

Results

GIB occurred in 1.5% and IMS in 3% of patients. Both were associated with worse outcomes in bivariate analysis. In multivariate models, GIB was not independently associated with mortality. IMS was independently associated with mortality (aOR 4.0, 95% CI 1.2–13.4) only when adjusting for persistent OF, but not when adjusting for OF of any duration. Renal, respiratory or cardiovascular OF of any duration, as well as persistent OF, had an independent and very strong association with all the outcome variables including mortality, clearly differentiating them from GIB and IMS.

Conclusion

GIB and IMS are markers of disease severity but do not show a consistent independent association with mortality comparable to the current RAC definition of OF.

Introduction

Alcohol is a common cause of acute pancreatitis, and ongoing consumption increases the risk of recurrent episodes. There are no international guidelines to direct behavioural or pharmacological interventions to reduce recurrence of alcohol-associated acute pancreatitis (AAP). Studies exploring the role of addiction medicine in patients with AAP are limited.

Aims & Methods

This study describes the uptake and role of the Addiction Medicine Unit (AMU), a specialist consultative service, in patients admitted with AAP. We conducted a retrospective cohort study including all inpatients diagnosed with AAP at a large multisite tertiary health service in Melbourne, Australia between May 2022 to May 2024. Patient demographics, diagnosis of alcohol use disorder (AUD) and pharmacological and non-pharmacological interventions provided by the AMU were obtained from the patient’s medical records.

Results

A total of 231 patients with 314 admissions with AAP were identified. Most were males (77.9%) with a median age of 44 years (IQR 21), with median bedside index of severity in acute pancreatitis (BISAP) score of 1 (IQR 1). Of the patients, 35 (11.1%) had necrotising pancreatitis, 30 (9.6%) required admission to the intensive care unit (ICU), and 1 patient died from AAP. The prevalence of AUD was 82.3%. Referral to the AMU occurred in 56.7% of admissions, predominantly among those with AUD (87.6%). Patients referred to the AMU had a higher median number of standard drinks per week (70 standards, range 6-385 standards) compared to those who were not referred (49 standards, range 1-301 standards) (p=0.024). The AMU recommended outpatient services alone in 40.4%, both pharmacological and outpatient interventions in 37.6%, and medications alone in 21.9%. Outpatient services included either a service for community-based assessment and counselling (86.4%), residential rehabilitation programs and/or detox services (5.8%), follow up in the AMU outpatient clinic (3.9%) or a combination of these outpatient services (3.9%). There were 137 (43.6%) admissions in which patients were commenced on medications for AUD. Topiramate (42.6%), and naltrexone (42.6%) were the most prescribed pharmacological agents by the AMU, followed by baclofen (9.8%), acamprosate (4.1%) and disulfiram (0.8%). Over the 2-year period, 54 (23.4%) were readmitted with AAP. Most patients were not readmitted within 30 days of discharge (73.2%) however there were 33 (10.5%) patients readmitted for pancreatitis or pancreatitis-related complications including pain or infection, and 18 (5.7%) readmitted to hospital for non-pancreatitis related reasons. Patients who were older (median 49 years) were more likely to be readmitted with AAP compared to those who were younger (median age 43 years) across the study period (p=0.05). There were six patients re-admitted with AAP with their index admission deemed related to an alcoholic binge without suspected underlying AUD. Of these six patients, only two were referred and reviewed by the AMU, with the other four patients not referred.

Conclusion

Our study highlights the critical role of the AMU in managing AAP, particularly given the high prevalence of concurrent AUD in this population. Despite this, significant gaps remain in screening for AUD and initiating referrals, resulting in only half of AAP patients being referred. Considering the substantial morbidity and healthcare cost associated with alcohol, efforts to improve referral practices during index admissions may be key to reduce readmissions for AAP and improve patient outcomes.

Introduction

Although we previously demonstrated that AAV8-hSPINK1 safely exhibited significant alleviation of chronic pancreatitis (CP) progression¹, the limited pancreas specificity of AAV8 leads to off-target expression of the transgenes. Additionally, the CMV promoter, as a ubiquitous promoter, lacks tissue preference, hindering its usage in AAV-mediated gene therapy for pancreatic diseases.

Aims & Methods

We aimed to construct a novel pancreas acini-specific promoter to restrict the ectopic expression of transgenes and further enhancing the precision of gene therapy for pancreatic diseases. By integrating human scRNA-seq database, the TiGER database, and our mouse RNA-seq data from Part II, we identified highly conserved genes that are richly expressed in pancreatic acini across species. Sequences surrounding the transcriptional start site (TSS, designated as +1) were selected as candidate compacted pancreas-specific promoters. We first validated transcriptional activity of the candidate promoters using dual-luciferase reporter assay. Subsequently, we packaged compacted promoters into AAV to drive ZsGreen gene expression and injected into mice. Pancreas and liver were collected and immunofluorescence, qRT-PCR, and Western blot were performed to characterised the efficiency and tissue selectivity of the candidate promoters. Finally, the synergistic effects of combining short enhancer fragments from human or rat amylase genes with the candidate promoters were assessed to enhance transcriptional activity.

Results

We selected the promoter sequences originated from hPRSS1 (408 bp), rCela1(-500/+8) (508 bp), rCela1(-205/+8) (213 bp), hSPINK1 (120 bp) as candidates. In vitro dual luciferase activity assays results indicated that the relative luciferase activities of hPRSS1 promoter and rCela1(-500/+8) promoter were 2.77±1.64 and 3.91±0.93, respectively (compared with CMV [100]), which were significantly higher than that of the empty vector group (0.199±0.20) (all P < 0.001). However, the rCela1(-205/+8) and hSPINK1 promoters exhibited no significant promoter activity. Compared to the CMV promoter, the ZsGreen expression levels driven by the hPRSS1 and rCela1(-500/+8) promoter were lower, whereas the pancreas-to-liver ZsGreen mRNA ratio demonstrated that both compacted promoters had pronounced pancreatic transduction preference, which elevated pancreatic-specific expression by 77.81- and 63.02-fold, respectively (all P < 0.001). We finally introduction of human amylase AMY2A (34 bp) and rat Amy2a3 (40 bp) enhancer into hPRSS1 and rCela1(-500/+8) promoters. The Amy2(rat)-hPRSS1 promoter markedly increased the pancreatic transduction efficiency by 8-fold, and was selected as the optimal compacted enhancer-promoter sequence.

Conclusion

The compact pancreatic acini-specific enhancer-promoter, Amy2(rat)-hPRSS1, dramatically improved the pancreas gene transfer efficiency in vivo and eliminating liver tropism, serving a promising tool for pancreas-specific gene therapy targeting exocrine pancreatic diseases, including acute pancreatitis, chronic pancreatitis, and precancerous lesions of pancreatic cancer.

References

1. Wang YC, Mao XT, Sun C, et al. Pancreas-directed AAV8-hSPINK1 gene therapy safely and effectively protects against pancreatitis in mice. Gut 2024;73:1142-1155.

Disclosure

All authors declare no conflicts of interest.

Introduction

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is widely recognized as the preferred diagnostic method for pancreatic lesions, achieving diagnostic accuracy rates between 78% and 95%. Rapid on-site evaluation (ROSE) improves adequacy rates but remains unavailable in many centers. In this context, we evaluated a simplified method, Visual On-Site Evaluation (VOSE), based on macroscopic evaluation of the biopsy sample, to predict histo-cytological adequacy without needing ROSE.
Primary aim: assess the accuracy of VOSE in predicting sample adequacy.
Secondary aims: evaluate the diagnostic yield of FNB and the potential reduction in unnecessary needle passes.

Aims & Methods

This prospective single-center study enrolled patients undergoing EUS-FNB for pancreatic lesions between January 2020 and February 2024.
VOSE parameters included the presence of a macroscopic visible core (MVC), number of specimens, and specimen length. Associations between VOSE findings and final histo-cytological adequacy were analyzed using Fisher’s exact test and Student’s t-test. A p-value < 0.05 was considered statistically significant. Study conducted at a university hospital center.

Results

Fifty-nine patients (57.6% male; mean age 67.9 ± 9.8 years) were included, contributing to a total of 59 pancreatic lesions. Across 218 passes performed, the overall sample adequacy rate was 91.5%.
Adequacy was significantly higher when using 22-G needles compared to 25-G needles (95.7% vs. 86.2%, p = 0.018). VOSE criteria (presence of MVC, multiple fragments, and long specimen) demonstrated a sensitivity of 52.3%, a specificity of 61.1%, and a positive predictive value (PPV) of 93.1% for predicting sample adequacy. Applying VOSE led to a 45% reduction in unnecessary additional passes.

Conclusion

EUS-FNB provides excellent diagnostic adequacy for pancreatic lesions, particularly with 22-G needles. The use of VOSE, a simple and reproducible macroscopic evaluation method, can reliably predict histo-cytological adequacy and substantially reduce the number of passes, offering a practical alternative in centers without ROSE availability.

References

1. El Chafic AH, Loren DE, Siddiqui AA. EUS-guided fine-needle biopsy of pancreatic masses: new tools, new techniques. Endosc Ultrasound. 2023;12(1):3-10.
2. Crinò SF, Larghi A, Bernardoni L, et al. EUS-guided fine-needle biopsy with or without ROSE for pancreatic masses: A multicenter randomized trial. Gastrointest Endosc. 2023;98(2):225-234.e3.
3. Bang JY, Hebert-Magee S, Navaneethan U, Hasan MK, Hawes R, Varadarajulu S. EUS-guided fine-needle biopsy of pancreatic masses: a meta-analysis comparing FNA and FNB. Gastrointest Endosc. 2022;95(5):893-905.e2.

Introduction

Pancreatic inflammation is often triggered by sustained intraductal pressure, commonly due to gallstones or endoscopic retrograde cholangiopancreatography (ERCP). In mouse models, transient pressure disrupts tight junction integrity via calcineurin. Another key regulator of pressure-induced epithelial responses is the mechanosensitive Ca²⁺ channel PIEZO1, which detects cell elongation, increases Ca²⁺ influx, and regulates cell proliferation and apoptosis. However, studying these processes in vitro remains challenging, limiting the development of targeted therapies for post-ERCP and gallstone-induced pancreatitis.

Aims & Methods

To overcome these limitations, we aimed to utilize apical-out pancreatic organoids (hPOCs) to model pressure-related disease mechanisms ex vivo.
To investigate this we generated hPOCs from pancreatic tissue of three cadaver donors. Polarity switching was induced by Matrigel removal. Conventional and apical-out hPOCs were analyzed by RNA sequencing and live-cell fluorescent imaging. Gene expression changes in response to 1 µM PIEZO1 activator (YODA1) were assessed by qRT-PCR.

Results

Polarity switching led to reduced PIEZO1 expression and decreased intraluminal pressure, resulting in downregulation of cytoskeletal and cell cycle-related genes (ACTB, VCL, LPXN, LMNA, cyclins) as well as pro-inflammatory cytokines (CXCL1-3, CXCL8).
Heatmap analysis of transcriptomic data revealed distinct gene expression patterns between apical-in and apical-out organoids. Apical-in organoids exhibited upregulation of cell cycle and cytoskeletal genes, suggesting increased proliferation, while apical-out organoids showed a quiescent phenotype with reduced proliferative activity.
Gene Ontology (GO) analysis confirmed that apical-in organoids were enriched in pathways related to chromosome segregation, mitotic progression, and microtubule organization, whereas apical-out organoids had lower expression of these genes.
Volcano plot analysis of differentially expressed genes identified significant upregulation of MKI67, CENPF, ASPM, and UHRF1 in apical-in organoids, indicative of a proliferation-driven state. Conversely, apical-out organoids showed enrichment in DUOXA2, NUPR1, VNN2, and GBP2, genes associated with oxidative stress and inflammatory response, supporting the hypothesis that apical-in organoids reflect a pressure-induced, inflammation-like state.
Furthermore, polarity switching resulted in enhanced Cl⁻ efflux via CFTR and ANO1, likely due to the absence of sustained intraluminal pressure. Pharmacological activation of PIEZO1 by YODA1 reversed the downregulation of pro-inflammatory cytokines in apical-out hPOCs, suggesting that PIEZO1 mediates the inflammatory phenotype observed in conventional organoids.

Conclusion

Our results suggest that conventional apical-in pancreatic organoids mimic a pressure-induced inflammatory state, driven by PIEZO1-dependent signaling. In contrast, apical-out organoids, which lack sustained luminal pressure, provide a more physiological model for studying epithelial homeostasis. This platform offers new opportunities for investigating pressure-induced pancreatitis and developing targeted therapeutic strategies.

Introduction

Endoscopic ultrasound (EUS) tissue acquisition requires rapid on-site evaluation (ROSE) to improve diagnostic yield with less needle passes; however, ROSE requires the presence of a cytopathologist and additional cost and time for slide staining and interpretation. Macroscopic on-site evaluation (MOSE) is the direct assessment of the tissue sample provided by EUS-guided fine needle biopsy (EUS-FNB) macroscopically, to detect whether it is sufficient or not.

Aims & Methods

Aim of this study was to evaluate the efficacy of MOSE in terms of tissue acquisition and diagnostic accuracy for abdominal solid lesions
This is a prospective and comparative study including 148 consecutive patients performing EUS-FNB for pancreatic and extrapancreatic solid lesions, randomized by alternate allocation to macroscopic on-site evaluation (MOSE) (74 patients) or to a conventional technique (74 patients), with two passes each. MOSE samples were differentiated into score 0: no visible material, score 1: only necrotic or haematic material, score 2: white core tissue ≤ 2 mm, or score 3: white core tissue > 2 mm. The conventional technique consisted in pushing all the needle content into a test tube for evaluation by the pathologist. In both groups, a 22 Gauge Franseen-tip needle biopsy was used.

Results

The overall diagnostic adequacy was 92.5% (137/148) and accuracy was 86.4% (128/148). The diagnostic accuracy was similar in the two groups: MOSE 87.8% (65/74 lesions), vs. conventional 81.0%, 60/74 lesions, p = 0.34). Regarding diagnostic adequacy, the MOSE technique was 95.9% (71/74 passes) compared to 91.8% (136/148 passes) with the conventional technique, p = 0.04. The accuracy increased according to the MOSE score evaluation: it was 49.3%, 68.9% and 81.3% in patients with score 1, score 2, and score 3, respectively. There was no statistically significant difference between the two groups with conclusive and inconclusive cytopathological results regarding size of the needle, number of needle passes, type of the needle and the specimen acquisition method.

Conclusion

The MOSE score showed a comparable diagnostic accuracy to the conventional technique. However, MOSE allows endoscopists to perform an inspective evaluation of the material, tends to perform better than the conventional technique in terms of diagnostic adequacy, and may potentially reduce the number of passes.