Evaluation of the Manchester classification system for chronic pancreatitis.

CONTEXT: Classifications of chronic pancreatitis based on either histologic (Marseilles) or endoscopic (Cambridge) criteria are not widely used. OBJECTIVE: The present study describes the development and validation of a three-stage clinical categorical classification system for chronic pancreatitis. DESIGN: Patients with a diagnosis of chronic pancreatitis (577.1: ICD-9) for 1993 were identified from records of the Hepatopancreaticobiliary service at a University hospital. Endoscopic or CT evidence of chronic pancreatitis were mandatory for inclusion. PATIENTS: Forty one patients met the criteria and were categorized according to a 3-stage system as mild, moderate or end-stage disease. MAIN OUTCOME MEASURE: The clinical course over the subsequent decade was followed by chart review with re-categorization of stage at each review. RESULTS: At the outset of the study, 18 (44%) patients were categorised as having mild disease, 19 (46%) as moderate and 4 (10%) as end-stage. The number of patients with mild disease fell over the subsequent 5 years and at the end of the 10-year chart study period, no patients were categorised as mild. The number of patients with diabetes at the outset of the study period was 2 (5%). At two years this was 3 (7%), five years 10 (24%) and 10 years was 25 (61%). CONCLUSIONS: These results show that the Manchester classification of chronic pancreatitis is both practical and feasible and now requires prospective evaluation and independent appraisal by other centres.

Quantitative analysis of plasma DNA in severe acute pancreatitis.

CONTEXT: Release of genomic DNA into plasma as a result of necrotic and apoptotic pathways is a feature of a range of human tumours. Severe acute pancreatitis is characterized by inflammation but may also be associated with accelerated apoptotic and necrotic pathways. OBJECTIVES: This study uses quantitative real-time PCR to measure free circulating DNA in patients with severe acute pancreatitis. PARTICIPANTS: Forty-three patients with severe acute pancreatitis, 12 patients with pancreatic cancer and 28 non-cancer controls undergoing laparoscopic cholecystectomy. METHODS: Plasma DNA was purified and quantified using the RNase P transcription assay and quantitative PCR. In pancreatitis patients, baseline samples were taken on admission and further samples taken at a median of 5 days into the disease course. RESULTS: Plasma DNA levels on admission in patients with acute pancreatitis (median: 0.40 ng/microL; range: 0.05-0.79 ng/microL) were significantly (P<0.001) lower than in non-cancer controls (median: 1.60 ng/microL; range: 0.45-9.10 ng/microL). In patients with acute pancreatitis, DNA levels significantly (P<0.001) fell during the disease course to a median value of 0.08 ng/microL (range: 0-0.53 ng/microL). CONCLUSION: This is the first study to use quantitative PCR to measure free plasma DNA in severe acute pancreatitis. The results show that plasma DNA is lower in patients with acute pancreatitis compared to control and that values fall further during the disease course.

The performance of organ dysfunction scores for the early prediction and management of severity in acute pancreatitis: an exploratory phase diagnostic study.

OBJECTIVE: To evaluate contemporary organ dysfunction scoring systems for early prediction of severity in acute pancreatitis (AP). METHODS: In a consecutive cohort of 181 patients with AP, organ dysfunction scores (logistic organ dysfunction system [LODS] score, Marshall organ dysfunction score, and sequential organ failure assessment score) were collected at 24 and 48 hours. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated on admission and 24 and 48 hours and C-reactive protein level measured at 48 hours. Patients who died or used critical care facilities (level 2/3) during admission were classed as severe. RESULTS: Area under curve for APACHE II score at admission was 0.78 (95% confidence interval, 0.69-0.86). At 24 hours, area under curve for LODS, Marshall organ dysfunction system, sequential organ failure assessment, and APACHE II scores were 0.82, 0.80, 0.80, and 0.82, respectively. The LODS score at cutoff of 1 achieved 90% sensitivity and 69% specificity, corresponding to a positive predictive value of 38%. Acute Physiology and Chronic Health Evaluation II score as a rule-out for selection of mild cases at a test threshold of 9 (scores ≤ 8 being selected) gives homogeneity of 91% and efficiency of 79%. CONCLUSIONS: Contemporary organ dysfunction scoring systems provides an objective guide to stratification of management, but there is no perfect score. All scores evaluated here perform equivalently at 24 hours. Acute Physiology and Chronic Health Evaluation II may have practical clinical value as a rule-out test.

Randomised, double blind, placebo controlled trial of intravenous antioxidant (n-acetylcysteine, selenium, vitamin C) therapy in severe acute pancreatitis.

BACKGROUND: Based on equivocal clinical data, intravenous antioxidant therapy has been used for the treatment of severe acute pancreatitis. To date there is no randomised comparison of this therapy in severe acute pancreatitis. METHODS: We conducted a randomised, double blind, placebo controlled trial of intravenous antioxidant (n-acetylcysteine, selenium, vitamin C) therapy in patients with predicted severe acute pancreatitis. Forty-three patients were enrolled from three hospitals in the Manchester (UK) area over the period June 2001 to November 2004. Randomisation stratified for APACHE-II score and hospital site, and delivered groups that were similar at baseline. RESULTS: Relative serum levels of antioxidants rose while markers of oxidative stress fell in the active treatment group during the course of the trial. However, at 7 days, there was no statistically significant difference in the primary end point, organ dysfunction (antioxidant vs placebo: 32% vs 17%, p = 0.33) or any secondary end point of organ dysfunction or patient outcome. CONCLUSIONS: This study provides no evidence to justify continued use of n-acetylcysteine, selenium, vitamin C based antioxidant therapy in severe acute pancreatitis. In the context of any future trial design, careful consideration must be given to the risks raised by the greater trend towards adverse outcome in patients in the treatment arm of this study.