Impact of early laxative administration on short-term mortality in critically ill acute pancreatitis patients: insights from the MIMIC-IV database

Acute pancreatitis (AP) carries a high risk of morbidity and mortality, and this risk is significantly amplified when the disease course requires intensive care. Although advances in supportive management have improved outcomes, effective pharmacological interventions targeting disease progression remain limited. Increasing evidence suggests that intestinal dysfunction, including impaired gastrointestinal motility, disruption of the gut barrier, and gut-derived inflammatory activation, contributes to systemic inflammation and organ dysfunction in AP. Laxatives are commonly used in the ICU to counter gastrointestinal motility disorders. However, the impact of early initiation on AP outcomes remains elusive. Leveraging the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, we carried out a retrospective cohort study. We enrolled adult patients who were admitted to the ICU with a primary diagnosis of AP. Early laxative exposure was defined as the receipt of any laxative medication within 48 h after ICU admission. All-cause mortality at 28 days served as the primary outcome measure. We used propensity score matching (PSM) to adjust for baseline differences between the two exposure groups. The association between early laxative exposure and mortality was examined using Kaplan–Meier curves and multivariable Cox regression models. We also evaluated the occurrence of acute kidney injury (AKI), invasive mechanical ventilation use, and sepsis as secondary outcomes. The study cohort comprised 1,061 patients, including 705 who received early laxatives and 356 who did not. After 1:1 PSM, 355 matched pairs were obtained, with all standardized mean differences < 0.1, indicating good balance. Early laxative administration was associated with significantly higher 28‑day survival by Kaplan–Meier analysis (log‑rank P = 0.002). Multivariable Cox proportional hazards regression, after adjustment for potential confounders, demonstrated that early laxative administration was independently associated with a decreased hazard of 28‑day mortality (HR, 0.464; 95% CI, 0.316–0.681; P < 0.001). Analysis of secondary endpoints showed that early laxative exposure conferred a significantly elevated risk of AKI (OR, 2.11; 95% CI, 1.42–3.13; P < 0.001). In contrast, its associations with the need for invasive mechanical ventilation and the occurrence of sepsis were not statistically significant. Among critically ill patients with acute pancreatitis, early laxative administration was associated with improved 28-day survival. Our results raise the possibility that early gastrointestinal modulation could serve as a modifiable factor influencing short‑term outcomes in AP. However, given the observational design and potential residual confounding, prospective studies are required to determine whether laxative therapy provides a causal clinical benefit.