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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
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\n\n\n\n\n'}],latestNews:[{slug:"intechopen-signs-new-contract-with-cepiec-china-for-distribution-of-open-access-books-20210319",title:"IntechOpen Signs New Contract with CEPIEC, China for Distribution of Open Access Books"},{slug:"150-million-downloads-and-counting-20210316",title:"150 Million Downloads and Counting"},{slug:"intechopen-secures-indefinite-content-preservation-with-clockss-20210309",title:"IntechOpen Secures Indefinite Content Preservation with CLOCKSS"},{slug:"intechopen-expands-to-all-global-amazon-channels-with-full-catalog-of-books-20210308",title:"IntechOpen Expands to All Global Amazon Channels with Full Catalog of Books"},{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"}]},book:{item:{type:"book",id:"6426",leadTitle:null,fullTitle:"Titanium Dioxide - Material for a Sustainable Environment",title:"Titanium Dioxide",subtitle:"Material for a Sustainable Environment",reviewType:"peer-reviewed",abstract:"Titanium dioxide is currently being used in many industrial products. It provides unique photocatalytic properties for water splitting and purification, bacterial inactivation, and organics degradation. It has also been widely used as the photoanode for dye-sensitized solar cells and coatings for self-cleaning surfaces, biomedical implants, and nanomedicine. This book covers various aspects of titanium dioxide nanomaterials including their unique one-dimensional, two-dimensional, mesoporous, and hierarchical nanostructures and their synthetic methods such as sol-gel, hydrothermal, anodic oxidation, and electrophoretic deposition, as well as its key applications in environmental and energy sectors. 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\r\n\tAntimicrobial peptides (AMPs) are found in single-cell and multiple-cells organisms such as bacteria, fungi, algae, insects, scorpions, frogs, and mammals. AMPs are peptides with a varying number (12-50 of amino acids residues) and they belong to the first line defense molecules of multicellular organisms. They have a broad-spectrum antimicrobial activity including bacteria, fungi, and viruses. More than 3000 AMPs have been discovered since the first discovery and isolation. AMPs are mostly synthesized as a precursor containing signal sequences that determine their localization in the cell. Next, the precursor molecules go through cleavage and formation of biologically active peptide. Target and mechanism of action of AMPs can be differing and depend on microorganism against which action is directed; by inhibiting proteins, by disrupting membrane integrity, by inhibiting DNA and RNA synthesis, or by interacting with intracellular targets.
\r\n\r\n\tThis book will thus aim to include information on AMPs and their targets and mechanisms of action.
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Latterly, she is selected as an African science leadership program fellow.",institutionString:"Suez Canal University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"5",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}],coeditorOne:{id:"346095",title:"Dr.",name:"Jorge",middleName:"Adrian",surname:"Masso-Silva",slug:"jorge-masso-silva",fullName:"Jorge Masso-Silva",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000034TvktQAC/Profile_Picture_1610961185642",biography:null,institutionString:"VA San Diego Healthcare System",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"VA San Diego Healthcare System",institutionURL:null,country:{name:"United States of America"}}},coeditorTwo:{id:"346088",title:"Dr.",name:"Anna",middleName:null,surname:"Savitskaya",slug:"anna-savitskaya",fullName:"Anna Savitskaya",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000034TvdsQAC/Profile_Picture_1610960064985",biography:'Savitskaya Anna, PhD, is a senior researcher at the Institute of Bioorganic Chemistry of Russian Academy of Science, Moscow, Russian Federation. Her research interests focus on microbiology, molecular genetics, and the use of microorganisms as producers of target proteins and analysis of intracellular protein interaction. Since 2008, she\'s been enrolled in PhD course at the Department of Chemical Technologies of Wood and Biotechnology of the Siberian State University of Science and Technology named after Academician M.F. Reshetnev, and has started working as a junior researcher at the biotechnology laboratory of the Krasnoyarsk agriculture Research Institute (Krasnoyarsk). In 2011, she underwent a six-month internship at the University of Ottawa (Canada) for which she won a grant from the President of the Russian Federation for training and internships in foreign higher educational institutions and research centers for the 2010/2011 academic year in priority areas of development of science, technology and technology in the Russian Federation. Since 2011, she has worked as a junior researcher at the Research Institute of Molecular Biology and Pathobiochemistry, KrasGMU named after prof. V.F. Voino-Yasenetsky. From 2012 to 2020, she worked as a senior lecturer/associate professor at the Department of Microbiology, KrasGMU named after prof. V.F. Voino-Yasenetsky. From 2014 to 2018, she studied at the graduate school of the University of Niigata (Japan) at the Department of Bacteriology. In 2018 she defended her thesis for a PhD degree in medical science on the topic "C-terminal dependent organization of the mycobacterial genome by a histone-like protein (C-terminal internally disturbed region-dependent organization of the mycobacterial genome by a histone-like protein)". She has carried out studies on heterogeneity of the population of fungi of the genus Fusarium, as well as studies on the selection of aptamers for bacteria S. enteritidis and S. typhymotium, and the development of testing systems using aptamers. She also did research on the role of the internal disordered region (IDR) in the functions of the mycobacterial DNA-binding protein MDP1 and its influence on the phenotype of mycobacteria. The results have been personally reported many times at international scientific conferences and published in scientific journals.',institutionString:"Institute of Bioorganic Chemistry",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Institute of Bioorganic Chemistry",institutionURL:null,country:{name:"Russia"}}},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"346794",firstName:"Mia",lastName:"Miskulin",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/346794/images/15795_n.png",email:"mia@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6045",title:"The Rise of Virulence and Antibiotic Resistance in Staphylococcus aureus",subtitle:null,isOpenForSubmission:!1,hash:"4f24bfdcb5cd606846da63b96000bed2",slug:"the-rise-of-virulence-and-antibiotic-resistance-in-staphylococcus-aureus",bookSignature:"Shymaa Enany and Laura E. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"39227",title:"Spectral Modeling and Numerical Simulation of Compressible Homogeneous Sheared Turbulence",doi:"10.5772/48617",slug:"spectral-modeling-and-numerical-simulation-of-compressible-homogeneous-sheared-turbulence",body:'This chapter is mainly in the area of the use of Rapid Distortion Theory (RDT) to clarify and to well better increase our understanding of the physics of the compressible turbulent flows. This theory is a computationally viable option for examining linear compressible flow physics in the absence of inertial effects. In this linear limit, the statistical evolution of incompressible homogeneous turbulence can be described completely in terms of closed spectral covariance equations (see Refs. (Hunt, 1990 & Savill, 1987) and references therein). Many papers in literature deal with homogeneous compressible turbulence and RDT solution (Cambon et al., 1993; Coleman & Mansour, 1991; Blaisdell et al., 1993, 1996; Durbin & Zeman, 1992; Jacquin et al., 1993; Livescu & Madnia, 2004; Riahi et al., 2007; Riahi, 2008; Riahi & Lili, 2011; Sarkar, 1995; Simone, 1995; Simone et al., 1997). These studies have yielded very valuable physical insight and closure model suggestions. In all the above works, the fluctuation equations are solved directly to infer turbulence physics. For the case of viscous compressible homogeneous shear flow in the RDT limit no analytical solutions are known. Simone et al. (1997) performed RDT simulations of homogeneous shear flow and showed that the role of the distortion Mach number,
A study of compressibility effects on structure and evolution of a sheared homogeneous turbulent flow is carried out using this theory (RDT). An analysis of the behavior of different terms appearing in the turbulent kinetic energy and the Reynolds stress equations permit to well identify compressibility effects which allow us to analyze performance of the compressible model of Fujiwara and Arakawa concerning the pressure-dilatation correlation (Riahi et al., 2007). The evaluation of this model stays in the field of RDT validity (Riahi & Lili, 2011).
Equilibrium states of homogeneous compressible turbulence subjected to rapid shear can be studied using rapid distortion theory (RDT) for large values of
The flow to be considered is a homogeneous, compressible turbulent shear flow where we retain the same RDT equations adopted by Simone (1995), Simone et al. (1997), Riahi et al. (2007) and Riahi (2008). The linearized equations of continuity, momentum and entropy controlling the fluctuating of velocity
where
The dot superscript denotes a substantial derivative along the mean flow trajectories related to mean field velocity
Equation (1) is derived from continuity equation
associated to isentropic fluctuations hypothesis
and leads to equation (1). So, the isentropic hypothesis
After these remarks, we consider the Fourier transform (denoted here by the symbol
where
and
In the Fourier space, velocity field is decomposed on solenoidal and dilatational contributions by adopting a local reference mark of Craya (Cambon et al., 1993):
where
By separating solenoidal and dilatational contributions, we introduce the spectrums of doubles correlations:
where
We then write evolution equations of these doubles correlations:
where
Numerical integration of these equations ((11)-(20)) is carried out using a simple second-order accurate scheme:
where the derivatives
In this section, results are presented and used to verify the validity of the RDT code. For this, tests of this code have been performed by comparing RDT results with those of direct numerical simulation (DNS) of Simone et al. (1997) for various values of initial gradient Mach number
Concerning the existence of the evolution zones where shocks develop, we neither observe any anomaly in physic parameters (no problem of realisability), nor any instability in the calculation course. In addition, it is important to specify that our code was not conceived to take explicitly into account the existence of shocks. However, we think that in the applications presented, the flow is not probably contaminated by the appearance of shocks.
Intrinsic parameters that characterize the flow include the initial turbulent Mach number
Table 1 lists ten simulations cases labelled A1, A2 … A10 corresponding to different values of the initial gradient Mach number
In these cases, the initial turbulent kinetic energy spectrum is similar to that used by Simone (1995),
where
Case | ||||
A1 | 0.25 | 2.7 | 10.7 | 296 |
A2 | 0.25 | 4 | 16 | 296 |
A3 | 0.25 | 8.3 | 33.1 | 296 |
A4 | 0.25 | 12 | 48 | 296 |
A5 | 0.25 | 16.5 | 66.2 | 296 |
A6 | 0.25 | 24 | 96.1 | 296 |
A7 | 0.25 | 32 | 128.1 | 296 |
A8 | 0.25 | 42.7 | 170.8 | 296 |
A9 | 0.25 | 53.4 | 213.5 | 296 |
A10 | 0.25 | 66.7 | 266.9 | 296 |
Initial parameters.
All Figures 1-8 validate RDT approach and numerical code for low values of the non-dimensional times
Histories of the turbulent kinetic energy for pure-shear flow: (a) DNS results of
Evolution of the turbulent kinetic energy (a) case A2 (
Histories of the non-dimensional production term -2
Evolution of the non-dimensional production term (a) case A2 (
Histories of the temporal energy growth rate for pure-shear flow: (a) DNS results of
Evolution of the turbulent kinetic energy growth rate (a) case A2 (
Histories of the solenoidal
Histories of the dilatational
In the compressible regime (
In Figures 9-11, we present evolutions of
Evolution of the non-dimensional production term with (a):
Evolution of
Evolution of
In conclusion, RDT is valid for small values of the non-dimensional times
The various curves of Figure 1(b) permit to determine different regimes of the flow (Riahi & Lili, 2011). This figure shows that there is an increase in the turbulent kinetic energy when
These different regimes permit to better understanding compressibility effects on structure of homogeneous sheared turbulence and to analyze the causes of turbulence structure modification generated by compressibility.
Several explanations were proposed these last years to analyze causes of the stabilising effect of compressibility which are still not cleared up.
The study of compressibility effects on the turbulent homogeneous shear flow behavior made these last years the objective of several researches as mentioned in the works of Blaisdell et al. (1993 & 1996) and Sarkar et al. (1991 & 1992). DNS developed by Sarkar (1995) show that the temporal growth rate of the turbulent kinetic energy is extensively influenced by compressibility. Simone et al. (1997) identified the new coupling term in the quasi-isentropic RDT equations, which was responsible for long-term stabilization, comparing incompressible and compressible RDT. They concluded that the modification of the compressible turbulence structure is due to linear processes.
The prediction of compressible turbulent flows by rapid distortion theory provides useful results which can be used to clarify the physics of the compressible turbulent flows and to study compressibility effects on structure of homogeneous sheared turbulence. This study is important for the analysis of various physical mechanisms which characteristic the turbulence. Thus, physical comprehension of compressibility effects on turbulence leads it possible to better predict compressible turbulent flows and to improve existing turbulence models. The Helmoltz decomposition of the velocity field in solenoidal and dilatational parts reveals two additional terms in the turbulent kinetic energy budget. Several studies of the behavior of the different terms present in this budget and the Reynolds stress equations show the role of the explicit compressible terms. From Simone et al. (1997) and Sarkar (1995), for the case in which the rate of shear is much larger than the rate of non-linear interactions of the turbulence, amplification of turbulent kinetic energy by the mean shear caused by compressibility is due to the implicit pressure-strain correlations effects and to the anisotropy of the Reynolds stress tensor. These authors also recommend to take into account correctly the explicit dilatational terms such as the pressure-dilatation correlation and the dilatational dissipation. In contrast, the role of explicit terms was over-estimated by Zeman (1990) and Sarkar et al. (1991). These last authors show that both those terms have a dissipative contribution in shear flow, leading to the reduced growth of the turbulent kinetic energy.
The study of the budget behaviors of the turbulent kinetic energy and the Reynolds stress anisotropy by RDT enables to better understand and explain compressibility effects on structure and evolution of a sheared homogeneous turbulence.
In the case of homogeneous turbulence, the turbulent kinetic energy is written (Simone, 1995) as:
in which
Figures 12(a), (b), (c) show the budget of the turbulent kinetic energy for three values of initial gradient Mach number (respectively 1, 12 and 66.7) which describe the various regimes of the flow (Riahi & Lili, 2011). It will be shown from Figures 12(b), (c) that the production
The turbulent kinetic energy budget (a) case A0 (
In conclusion, compressibility affects more the turbulent production term which represents the dominating parameter in the turbulent kinetic energy budget. In the compressible regime, the production becomes preponderant. This property is already observed in the analysis of the budget of the Reynolds stress equations related to
In Figures 13(a), (b), (c), (d) are represented the different components of the anisotropy tensor
Components evolution of the anisotropy tensor (a)
RDT is also used to determine equilibrium states in the compressible regime (Riahi & Lili, 2011) in particular for large values of
Another interesting property of the pressure-released regime is the quadratic increase of
Evolution of the relevant component of the Reynolds stress anisotropy tensor
Quadratic evolution of
Table 2 lists equilibrium values of the normalized dissipation rate due to dilatation
Figure 16 shows variation of the equilibrium normalized pressure variance
initial turbulent Mach number)) (Riahi & Lili, 2011). From this figure, it can be seen that this parameter can be written as
Equilibrium parameters | 0.25 | 0.4 | 0.5 | 0.6 |
0.0410 | 0.0277 | 0.0230 | 0.0197 | |
0.000387 | 0.000311 | 0.000280 | 0.000257 | |
0.00937 | 0.00278 | 0.00156 | 0.000973 |
Equilibrium values of the normalized dissipation rate due to dilatation, the normalized pressure-dilatation and the normalized pressure variance for various initial turbulent Mach number
Variation of the equilibrium normalized pressure variance with various initial turbulent Mach number (
RDT is an efficient and accurate method for testing linear turbulence models. The Fujiwara and Arakawa model (1995) has been proposed in literature for pressure-dilatation correlation studying compressible turbulence. In order to verify its capacity to describe the homogeneous compressible flow, since it was established to this objective, three cases of the initial gradient Mach number (
The model suggested by Fujiwara and Arakawa (1995) for the pressure-dilatation correlation takes into account the compressible part (dilatational) of the kinetic energy (
where
Comparison between RDT and Fujiwara and Arakawa (1995) model results concerning the pressure-dilatation correlation term
Evolution of the pressure dilatation correlation term
Rapid distortion theory (RDT) is a computationally viable option for examining linear compressible flow physics in the absence of inertial effects. Evolution of compressible homogeneous turbulence has been described completely by finding numerical solutions obtained by solving linear double correlations spectra evolution. Numerical integration of these equations has been carried out using a second-order simple and accurate scheme. This numerical method has proved more stable and faster and allows in particular to obtain accurately the asymptotic behavior of the turbulence parameters (for large values of
Agreement of RDT with DNS (Simone et al., 1997) found for large values of
In conclusion, after a critical analysis, we were able to justify that RDT permits to well identify compressibility effects in order to develop models taking them into account satisfactorily. The analysis of rapid distortion theory showed that it is possible to better understand the compressible turbulent flows. In addition, RDT is valid to predict asymptotic equilibrium states for compressible homogeneous sheared turbulence for large values of initial gradient Mach number (pressure-released regime). RDT is an efficient method for testing linear contribution of turbulence models.
RDT Rapid Distortion Theory
DNS Direct Numerical Simulation
gradient Mach number, initial gradient Mach number | |
turbulent Mach number, initial turbulent Mach number | |
magnitude of the mean velocity gradient | |
velocity fluctuation | |
pressure fluctuation | |
mean density | |
kinematic viscosity | |
mean velocity gradient | |
mean sound speed | |
time-step size | |
turbulent kinetic energy | |
anisotropy tensor | |
initial total (solenoidal and dilatational) dissipation rate of turbulent kinetic energy | |
initial turbulent Reynolds number | |
initial rapidity of the shear | |
ratio of specific heats |
Acute pancreatitis (AP) refers to the sudden inflammation of the pancreas, and it may be confined to the pancreas, or more life-threatening, affecting all organs and systems [1–5]. Recurrence is experienced in 15–30% of patients, and 5–25% can develop chronic pancreatitis. It progresses mildly in 80% of patients and resolves with treatment, but in cases of severe AP, complications such as organ failure and pancreatic necrosis may develop, with mortality of around 30% recorded in this group [2, 4, 5]. AP is an acute gastrointestinal disease that requires hospitalization, and is the most common cause of admission to the emergency room worldwide [1, 6, 7]. Hospital admissions for AP in the United States are in the region of 270,000/year, with a mortality rate of 30% in severe cases. Death is due to systemic inflammatory response syndrome (SIRS) and organ failure in the first two weeks, while death after two weeks can be attributed to sepsis and complications [3, 6, 8, 9].
\nGallstones are the most common etiology of AP, being responsible for 40–70% of AP cases [10–12]. The ease at which small gallstones can pass into the bile duct make AP more common in this patient group [13]. Although alcohol is commonly blamed as the second most common cause, the link between alcohol and AP is unclear, as AP is seen in only a small number of alcoholics [2, 14, 15]. Recent studies have suggested that alcohol increases the oxidative metabolism in the acinar cells of the pancreas, thereby causing mitochondrial dysfunction and cell death. This increases also the production of acetaldehyde in the pancreatic stellate cells, and increases circulating lipopolysaccharide and tumor necrosis factor alpha (TNFα), leading to fibrosis in the pancreas [16, 17]. Alcohol has also been reported to increase the viscosity of pancreatic juice and to cause ductal obstructions. That said, it has also been suggested that genetic factors play a role in the development of AP,based on the low incidence of AP in people with chronic alcohol consumption [2, 15, 18]. Other causes have been identified as Hypertriglyceridemia (HTR), and diabetes, hypothyroidism, pregnancy and obesity that cause HTR [1]. Patients with a body mass index (BMI) >35 are at risk of both HTR and AP, while those with serum triglyceride levels >1000 mg/dl are at greater risk [19–21]. Following endoscopic retrograde cholangiopancreatography (ERCP) performed by inexperienced practitioners, patients with Sphincter of Oddi dysfunctions may develop AP following ERCP due to difficult cannulation [22].
\nAP can also occur due to drugs at a rate of 0.1–0.5% [2, 23–25]. Many drugs have been identified that cause acute pancreatitis. Drugs cause AP by different mechanisms. While some drugs cause direct toxicity to the pancreas (eg, diuretics, sulfonamides), some drugs cause acute pancreatitis by causing an immunological reaction (eg, 6-mercaptopurine, amino salicylates, sulfonamides). Diuretics and azothiopurine cause direct ischemia, while hormones such as steroids and estrogen cause vascular thrombosis or ischemic pancreatitis by decreasing the viskosity of the pancreatic juice. Toxic metabolites of drugs such as valproic acid and tetracycline may accumulate in the pancreas and cause pancreatitis [2, 26, 27].
\nAP cases have been reported associated with such infectious diseases as Mumps, Coxsackievirus, Hepatitis B, Cytomegalovirus, Varicella-Zoster, herpes simplex and human immunodeficiency virus (HIV) among the viruses; with Mycoplasma, Legionella, Leptospira and Salmonella among the bacteria; with Aspergillus among the fungi; and with Toxoplasma and Cryptosporidium among the parasites [2, 27, 28] . There have been reports of cases of AP with the recent SARS-CoV-2 infection at the heart of the current global pandemic [29, 30]. In a review of current literature, AP was found to be detected in 17% of patients hospitalized due to Covid-19 [29]. Although tests for specific infectious agents are not generally recommended in AP patients, Covid-19 infection should also be kept in mind in AP cases during the pandemic [30].
\nConcerning other rare causes, pancreatic injury following trauma is an extremely rare condition due to its retroperitoneal nature. Pancreatic duct injuries may occur due to blunt or penetrating traumas [31], while AP may occur due to gallbladder sludge, tumors, autoimmune pancreatitis, hypercalcemia, anatomical and physiological anomalies (pancreatic divisum, biliary cysts, pancreaticobiliary malunion, large juxta-ampullary diverticula, annular pancreas and Sphincter of Oddi dysfunction), and vasculitis [27, 32–36]. Ischemic AP can also be seen after major cardiovascular operations [27, 37, 38]. Patients with an unknown etiology after history-taking, physical examination, laboratory tests, imaging methods and advanced tests are classified as idiopathic. In the event of recurrent AP attacks in this patient group and AP at a young age, genetic factors should be investigated [27, 39].
\nAs its main mechanism, AP blockades the secretion of enzymes while the synthesis of enzymes continues [2, 40]. Under normal conditions, trypsinogen is produced in the pancreas and secreted into the duodenum where it is converted into protease trypsin, but in cases where secretion is blocked, trypsin continues to be produced in pancreatic acinar cells. While activation continues, elimination is inhibited, and the active trypsin damages the vascular endothelium, interstitium and acinar cells [2, 40, 41]. As a result, autodigestion begins in the pancreas,and ischemia occurs at a tissue level in the pancreas due to the vasoconstriction and stasis of the capillary vessels. The activation of granulocytes and macrophages in response to these events causes a release of proinflammatory cytokines (tumor necrosis factor, interleukins 1, 6 and 8), arachidonic acid metabolites (prostaglandins, platelet activating factor and leukotrienes), proteolytic and lipolytic enzymes, and reactive oxygen metabolites [2, 27, 42, 43]. All of these factors together cause damage to the pancreatic tissue. In general, the inflammation is locally self-limiting, buton occasions, inflammatory agents may cause a systemic response, leading to the damage and failure of distant organs. This, in turn, may result in Acute Respiratory Distress Syndrome (ARDS), pleural effusion, acute renal failure, shock, and even death [2, 27, 44, 45].
\nPatients withAP present to the emergency room with sudden and severe abdominal pain that usually starts in the epigastric region. In patients with gallstones, the pain spreads to the right upper quadrant and is more sharply limited. In 50% of patients, the pain spreads to the back, and is felt around the entire abdomen, like a belt. Nausea and vomiting may accompany,and in rare cases there may be pain on the left side of the abdomen [2, 46, 48–50].
\nPhysical examination findings can vary, depending on the severity of AP and any accompanying diseases. Initial findings typically include mild or generalized tenderness upon abdominal palpation, distension and diminished bowel sounds. In cases of obstruction due to gallstones, jaundice may be observed, while in severe AP, fever, hypotension, tachycardia, tachypnea and hypoxemia may be observed. In cases of pancreatic necrosis, ecchymotic lesions can be seen in the periumbilical region (Cullen’s sign) or on the flanks (Gray Turner’s sign) [2, 27, 51, 52].
\nDiagnosis is established based on the presence of two of three criteria: 1) Presence of clinical findings consistent with AP, 2) serum lipase or amylase levels three times greater than normal, and 3) characteristic findings of AP on imaging [2, 27, 47–49].
\nIn AP, enzymes pass from the basolateral membrane to the interstitial area, and then on to the systemic circulation due to the blockade of the secretion ofpancreatic enzymes, while the synthesis of enzymes continues, resulting in increased levels of pancreatic enzymes in the blood.
\nAt the onset of AP, serum amylase starts to increase within 6–12 hours, peaks at 48 hours, and returns to normal within 3–5 days, although no increase in amylase levels will be observed in alcohol-induced pancreatitis and AP due to hypertriglyceridemia. Sensitivity and specificity in diagnosis are 67–83% and 85–98%, respectively [2, 27, 49, 53, 54]. Elevated amylase levels may also be seen in non-pancreatic diseases, such as renal failure, salivary gland diseases, acute appendicitis, cholecystitis, perforations, intestinal obstructions or intestinal ischemia, and gynecological diseases. For these reasons, amylase alone is not sufficient for a diagnosis of AP [2, 49, 50]. The increase in serum lipase levels in AP is more specific. Following the onset of symptoms, the levels begin to increase within 8–10 hours, peak at 24 hours, return to normal within 8–14 days, with a sensitivity of 82–100% [2, 49, 53, 55], and may increase in alcohol-induced AP and AP due to hypertriglyceridemia. It is useful in delayed patients who present 24 hours after the onset of pain [49, 55, 56]. Aside from amylase-lipase, liver and kidney tests,a complete blood count should also be made in AP, as this will allow the assessment of the patient’s clinical condition, the early identification of complications and the detection of organ failure, and will aid in a therapeutic evaluation. An alanine aminotransferase (ALT) liver function test value in excess of 150 U/L indicates gallstones [2, 47, 48]. There are also specific tests for AP that are not routinely used. Among the enzymes with early elevation are trypsinogen-activating peptide, urinary and serum trypsinogen and trypsin, phospholipase, carboxypeptidase, carboxyl ester lipase, colipase and pancreatic isoamylase [57–59], and an increase is also observed in inflammatory mediators such as C-reactive protein (CRP), interleukin IL-6, IL-8, IL-10, tumor necrosis factor (TNF) and PMN elastase. The elevation of inflammatory mediators is usually proportional to the severity of AP. A CRP level above 150 mg/dl within the first 48 hours has been associated with severe AP [60, 61].
\nImaging can aid in determining the etiology of AP, or complications due to AP. Abdominal and chest radiographs may reveal appearances of pleural effusion, atelectasis and ileus accompanying AP. Radiographs should be evaluated to rule out other causes of abdominal pain. Abdominal ultrasound should be performed on every patient with suspected AP, and USG can detect findings that support AP, if present, such as gallstones, obstructions in the common bile duct, intraabdominal free fluid and diffuse enlarged and hypoechoic appearance in the pancreas, as well as peripancreatic fluid, necrosis and abscesses. A normal USG cannot exclude AP [2, 27, 47–49, 62], while Contrast-Enhanced Computed Tomography (CECT) has a sensitivity of 90% in the diagnosis of AP. However, AP is not routinely recommended for diagnosis, since it is mild and uncomplicated in most patients [2, 47–49], but may be recommended in cases where other causes of acute abdomen cannot be excluded, or for patients who show no improvement within 48–72 hours [49, 63, 64].
\nAmong the patients considered for CECT, MRI is recommended rather that CECT for those with renal failure, pregnant patients and those with allergies to IV contrast agents [49, 63].
\nSerum triglyceride levels must be examined in patients with normal test results, but with a strong suspicion of AP, in those with pancreatic tumors aged over 40 years, in the presence of genetic factors in patients under the age of 30 and in recurrent AP cases [39, 49].
\nOther diseases that may cause abdominal pain should be excluded in a differential diagnosis.In particular, peptic ulcer disease, choledocholithiasis, cholangitis, biliary obstruction, cholecystitis, perforated viscus, intestinal obstruction, mesenteric ischemia and hepatitis should be considered in differential diagnosis due to their clinical similarities to AP [2, 27] .
\nAP can be classified into two groups as mild AP, in which patients have no accompanying organ failure, and recover and can be orally fed within 48 hours; and severe AP, which is accompanied by organ failure and a lack of response to treatment. Most patients with severe AP have not suffered organ failure at the time of admission to emergency room, and so may be evaluated as mild AP,but deteriorate rapidly due to inadequate hydration and inadequate treatment. As such, the severity of the disease should be determined along at the time of diagnosis in the emergency room, and treatment should be planned accordingly [47–49, 65].
\nAccording to the Atlanta classification, severe AP is characterized by resistant/persistent organ failure with no improvement within 48 hours, although in the absence of organ failure, the presence of local complications alone is an indicator of severe AP [66]. Patients who develop transient organ failure alongside local complications are classified as moderately severe AP (Table 1). The Atlanta classification evaluates the presence of organ failure based on Marshall’s organ failure criteria. Accordingly, the presence of shock (systolic BP <90 mmHg), pulmonary failure (PaO2 < 60 mmHg), renal failure (creatinine >2 despite adequate hydration), and/or the presence of gastrointestinal bleeding (>500 ml blood loss within 24 hours) should be evaluated as organ failure [47, 49, 67].
\nMild AP | \nModerately AP | \nSevere AP | \n
---|---|---|
Absence of local complications | \nPeripancreatic fluid collection Pancreatic or peripancreatic necrosis(sterile or infected) Gastric outlet disfunction Splenic or portal vein thrombosis Colonic necrosis AND/OR | \nGI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d | \n
Absence of organ failure | \n\n | |
\n | GI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d | \n\n |
Atlanta classification 2015.
Besides the Atlanta classification, several scoring systems have been proposed for the determination of the severity in AP. These include Ranson’s criteria,Acute Physiology and Chronic Health Examination-II, modified Glasgow score, Bedside Index for Severity in Acute Pancreatitis and the Balthazar CT Severity Index,none of which has been shown to be superior to any other, and they have only limited use in the emergency room, as they rely on too many parameters, and some give results only after 48 hours [68, 69]. The assessment of the patient in the emergency department is of utmost importance, with patient-related risk factors such as age, weight, comorbidities and vital signs as well as laboratory findings all being evaluated together (Table 2) [47, 48, 56, 65].
\nPatient characteristics | \nThe systemic inflammatory response syndrome (SIRS) | \nLaboratory findings | \nRadiology findings | \n
---|---|---|---|
Age > 55 years Obesity (BMI >30 kg/m2) Altered mental status Comorbid disease | \npulse >90 beats/min respirations >20/min or PaCO2 > 32 mmHg temperature > 38°C or < 36°C WBC count >12,000 or < 4,000 cells/mm3 or > 10% immature neutrophils (bands) | \nBUN >20 mg/dl Rising BUN HCT >44% Rising HCT Elevated creatinine | \nPleural effusions Pulmonary infiltrates Multiple or extensive extrapancreatic collections | \n
Initial assessment for risk of severe AP.
The initial approach to AP involves aggressive fluid therapy, pain management and nutritional support. In AP, there is a large amount of fluid deficit due to losses from vomiting, reduced oral intake, passage of fluid into the third space, respiration and sweating. If the patient has no additional cardiovascular or renal disease, fluid replacement should be initiated at 5–10 ml/kg/hour. For patients presenting with evidence of hypovolemia and shock, 3 ml/kg of fluid should be given for 8–12 hours following a fluid bolus of 20 ml/kg in 30 minutes, with isotonic normal saline preferred as the fluid [47–49, 70–72]. A prospective study found hydration with Ringer’s lactate solution to be more beneficial, although Ringer’s lactate solution has been shown to activate trypsin in acinar cells, thereby making the patient more susceptible to injury due to its low pH. With normal saline, there is a risk of developing non-anion gap metabolic acidosis, and patients should be monitored accordingly during fluid replacement [2, 72]. An assessment should be made after 6, 24 and 48 hours to as certain whether the fluid administered is sufficient. With adequate hydration, the heart rate should drop below 120/min, mean arterial pressure (MAP) should be maintained between 65 and 85, and hematocrit (HCT) should be 35–44%. If the BUN value is initially high, a decrease upon hydration is an indicator of adequate hydration. Changes in blood urea nitrogen (BUN) values within the first 24 hours are particularly important [27, 48, 49, 73]. If the BUN values continue to be high, or increase even further, acute tubular necrosis or resistant volume deficit should be suspected [27, 47, 48, 65, 75]. Another parameter that should be monitored during hydration is hematocrit. Continued hemoconcentration for more than 24 hours suggests the development of necrotizing pancreatitis, and so the patient’s urine output, BUN and HCT values should be closely monitored. The development of severe pancreatitis should be considered in patients who do not respond to aggressive hydration for 6–12 hours [47–49].
\nAdequate hydration and the resolution of hypovolemia relieve ischemic pain secondary to hemoconcentration. Nevertheless, opioid analgesics are recommended for rapid pain management. Fentanyl can be used safely, especially in patients with kidney failure, in which intravenous (IV) fentanyl of 20–50 microgram is administered slowly over 10 minutes. Meperidine can be used as an alternative to morphine due to the spasm effect of morphine on the Sphincter of Oddi [2, 27, 76, 77].
\nAP patients should be followed closely for 24 hours, with continued monitoring of blood pressure, temperature, pulse, oxygen saturation and urine output. Blood tests should be monitored for hematocrit, BUN and electrolytes (calcium, magnesium), and blood glucose should be maintained between 180 and 200 mg/dl [2, 27, 47]. Intensive care follow-up is required for patients whose vital signs and laboratory values are unstable and / or continue (Table 3) [47].
\nVital signs | \nLaboratuary findings | \nPatient condition | \n
---|---|---|
pulse <40 or > 150 beats/min; systolic arterial pressure < 80 mmHg (<10.7 kPa) or mean arterial pressure < 60 or diastolic arterial pressure > 120 mmHg respiratory rate > 35 breaths/min; | \nserum sodium <110 mmol/l or > 170 mmol/l; serum potassium<2.0 mmol/l or > 7.0 mmol/l; paO2 < 50 mmHg pH < 7.1 or > 7.7; serum glucose >800 mg/dl (>44.4 mmol/L); mmol/L); serum calcium >15 mg/dl (>3.75 | \ncoma. Furthermore, a patient with severe acute pancreatitis as defined by the revised Atlanta Classification (i.e. persistent organ failure) | \n
Assessment for intensive care.
It is no longer recommended to stop oral intake until the AP has fully resolved and the enzymes have returned to normal limits in order to put the pancreas at rest. Patients ceasing oral intake may develop atrophy in the mucosa of gastrointestinal tract [27, 47–49, 78, 79], and so oral feeding should be initiated in patients without nausea, vomiting or ileus and with relieved pain, as soon as they can tolerate [47–49, 79–81]. Liquid, light and low-fat foods should be given at first [82]. In cases of severe AP, enteral feeding may be initiated in patients who are still unable to tolerate oral feeding after 5 days, and in those with complications. For enteral nutrition, a nasojejunal or nasogastric tube should be used for feeding. A nasogastric tube insertion may be easy, but there is a risk of aspiration, while a nasojejunal tube requires an operation. Depending on the conditions, both methods can help provide effective nutrition [49, 48, 82]. If the goal of enteral nutrition is not achieved within 48–72 hours, or if the patient cannot tolerate, parenteral nutrition should be initiated [80, 81, 83].
\n20% of patients develop extrapancreatic infections that may be cholangitis, catheter infection, urinary tract infection or pneumonia. Prophylactic ABs, even if severe, are not routinely recommended in AP without an unidentified focus of infection or presence of infection. ABs for infective necrosis prophylaxis are not recommended, even for patients with sterile necrosis [2, 27, 47–49, 65, 84, 85].
\nIf, during the follow-up of moderately severe or severe AP patients, signs of sepsis appear, no improvement occurs within 72 hours or the condition deteriorates gradually, then complications should be suspected and a CECT should be performed.
\nAcute peripancreatic fluid collection occurs early, and has no specific wall. It resorbs spontaneously [27, 49, 117].
\nNecrotizing pancreatitis can involve both the pancreas and peripancreatic tissues. A variable amount of fluid and necrotic tissue may develop within the necrosis,and is known as Acute Necrotic Collection (ANC) when a clear wall cannot be defined, and as Wall-off Necrosis (WON) when there is a mature, encapsulated and well-defined wall. WON is a pancreatic pseudocyst that occurs around 4 weeks after an AP attack, and that has a noticeable wall, for which drainage may be required. In either case, the necrotic area may be sterile or infected, and the type of treatment is determined based on the presence or absence of infection [84, 86–88].
\nInfection should be suspected in patients with pancreatic or extrapancreatic necrosis upon clinical deterioration or a lack of improvement within 7–10 days of hospitalization. Infectious agents are usually of intestinal origin (such as Escherichia coli, Pseudomonas, Klebsiella and Enterococcus), and may be suspected with the emergence of clinical signs of infection in patients and the presence of gas around the pancreas on imaging [89, 90]. Empirical AB may be initiated in these patients, with ABs that can penetrate the pancreas well (carbapenem alone; or quinolone, ceftazidime, or cefepime combined with an anaerobic agent such as metronidazole)being recommended [27, 48, 49]. Fine needle aspiration (FNA) or sampling is not recommended in such patients. Necrosectomy may be scheduled for patients who show no improvement, but should be delayed as much as possible, since many patients respond well to AB therapy [49, 90–92]. Antibiotic therapy should have been completed 4 weeks prior to a decision of necrosectomy. For the necrestomy, endoscopic or invasive percutaneous procedures should be tried first, and if these fail, surgery should be scheduled [47–49, 91–93].
\nIn patients with necrotizing pancreatitis, sterile necrotizing pancreatitis should be suspected when there is no improvement despite treatment, and no clear clinical or imaging findings of infection. In such cases, FNA sampling is indicated, and if the collected material is sterile, there is no need to continue the ABs. Even ABs cannot prevent sterile necrosis from turning into infected necrosis [47, 48, 94]. In sterile necrosis in the absence of any sign of infection, interventions will be required in the following cases:
Continued obstruction of the gastric outlet, intestine or bile ducts, caused by mass effects after 4–8 weeks following the onset of acute pancreatitis.
Persistant symptoms (e.g. abdominal pain, nausea, vomiting, anorexia or weight loss) identified more than eight weeks following the onset of acute pancreatitis.
Disconnected duct syndrome (full transection of the pancreatic duct) with persistent symptomatic collections with necrosis (e.g., pain, obstruction) more than 8 weeks following the onset of acute pancreatitis.
Aside from these, CT and FNA should be repeated 5–7 days later in patients with sterile necrosis detected by CECT and FNA, but with signs of systemic toxicity [49, 47].
\nThe much rarer complications include peripancreatic vascular complications, splanchnic vein thrombosis, abdominal compartment syndrome and pseudoaneurysm. Furthermore, patients may risk developing diabetes in the following periods [27, 47, 95].
\nRespiratuar insufficiency includes pneumonia, atelectasis, and ARDS. Renal complications are prerenal azotemia, hypotansion and acute tubuler necrosis. Shock is caused by third space losses, vomiting and interstitial edema. Hypo-hyperglicemia, coagulation disorders, fat necrosis and pancreatic encphalophaty are other rare systemic complications of AP [27].
\nThe detection and treatment of the underlying diseases that cause AP are as important as AP itself. Most gallstones that pass into the common bile duct advance to the intestines, and are excreted with feces. However, stones that cause obstructions to the pancreatic duct and/or biliary ducts may result in severe AP and/or cholangitis. ERCP is recommended within the first 24 hours for AP patients with stones detected as causing an obstruction. The removal of stones by via a sphincterotomy with ERCP prevents both severe AP and the cholangitis and future development of biliary AP. ERCP should be performed within the first 24 hours in AP patients due to gallstones accompanied by acute cholangitis. A papillotomy, or the surgical removal of stones, with ERCP reduces the severity of AP [47, 49, 96–98]. It has been reported that mortality decreases with early ERCP in patients with no cholangitis, with biliary duct obstructions, and with elevated liver function test scores. That said, it is unnecessary to perform ERCP within the first 24 hours on patients with no increase in liver function tests, with therapeutic ERCP recommended for such patients before or during the cholecystectomy. It is recommended that EUS and MRCP be performed prior to ERCP in patients without cholangitis or jaundice, but with suspected choledocholithiasis, pregnant women and patients on whom ERCP cannot be performed anatomically [47–49, 65, 99].
\nThe removal of stones through the use of ERCP in patients without cholangitis can prevent the development of AP in the future, but it cannot prevent the development of biliary colic or cholecystitis. Accordingly, cholecystectomy is recommended prior to discharge in patients with mild AP and with gallstones [47–49, 65, 100–103]. Preoperative MRCP or EUS, or intraoperative cholangiography may be carried out for the selection of patients with common bile duct stones who need to be treated through an operative bile duct exploration or endoscopic sphincterotomy during a cholecystectomy [47, 49, 99]. A cholecystectomy may be avoided in ineligible elderly patients (>80 years of age), particularly if a sphincterotomy has already been performed [47, 49, 96, 97]. A cholecystectomy should be performed in patients with gallbladder sludge and AP. In patients with necrotizing biliary AP, cholecystectomies should be delayed until the active inflammation subsides and fluid collections have resolved or stabilized. If collection takes longer than 6 weeks to resolve, the cholecystectomy should be delayed until it can be performed safely [47–49, 65]. Asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis require no surgical intervention, regardless of the size, location and/or extension. In asymptomatic patients with infected necrosis, surgical, radiological and/or endoscopic drainage should be delayed for more than 4 weeks to allow for the liquefaction of the content and the development of a fibrous wall around the necrosis (WON). Minimally invasive necrosectomy methods are preferred in symptomatic patients with infected necrosis [47–49, 84, 87]. Percutaneous drainage and/or endoscopic drainage/debridement are minimally invasive alternatives to open surgery [104].
\nAlthough new guidelines have been published, there are several knowledge gaps identified in the initial management of the AP. Risk stratification of patients with AP is important to ensure the appropriate level of care. Therefore, there is a need to develop fast, easy and practical systems that can be used in the emergency room. There is also a need to define targeted therapies in AP. Future research will enable prevention of relapse, chronicity, and cancer development, improvement of quality of life and reduction of mortality.
\nNo funding support.
\nThe authors declare no conflict of interest.
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