Morbimortality indicators in severe acute pancreatitis.

OBJECTIVE: The aim of this study was to determine the factors related to the development of systemic complications, mortality and pancreatic necrosis in patients with severe acute pancreatitis. PATIENTS: Thirty-nine patients (22.3%) out of 175 patients with acute pancreatitis who were admitted to our center, had an APACHE II score greater than 8; they were classified as having severe acute pancreatitis and were evaluated in the study. MAIN OUTCOME MEASURES: Sepsis-related Organ Failure Assessment (SOFA) and Marshall scores were obtained. The variables analyzed were age, sex, etiology, hematocrit, leukocyte count, CRP level, CT findings and length of hospital stay. These variables were related to the development of systemic complications, mortality and necrotizing pancreatitis. RESULTS: The mean APACHE II value of the patients included was 11.6+/-3.1, the mean SOFA score was 3.2+/-2.0 and the Marshall score was 1.5+/-1.9. Eleven patients developed necrotizing pancreatitis. The mortality rate among severe acute pancreatitis patients was 3 out of 39 (7.7%). Variables found to be related to systemic complications were the APACHE II score as well as SOFA and Marshall scores greater than 3. The variables related to mortality were SOFA score greater than 3 and leukocytosis greater than 19,000 mm(-3). CRP greater than 19.5 mg/dL and length of hospital stay were related to necrotizing pancreatitis. CONCLUSIONS: The scoring systems, especially the SOFA score, were related to the development of systemic complications and mortality. CRP showed a relationship to necrotizing pancreatitis. There was no relationship between the evaluated scoring systems and necrotizing pancreatitis in patients with severe acute pancreatitis.

Changes in the management of patients with severe acute pancreatitis.

BACKGROUND: Severe acute pancreatitis is present in up to 25% of patients with acute pancreatitis, with considerable mortality. Changes in the management of acute pancreatitis in the last 2 decades contributed to reduce the mortality. AIM: To show the evolution in the management of severe acute pancreatitis, comparing two different approaches. METHODS: All patients with severe acute pancreatitis from 1999 to 2005 were included. We compared the results of a retrospective review from 1999 to 2002 (group A) with a prospective protocol, from 2003 to 2005 (group B). In group A severe pancreatitis was defined by the presence of systemic or local complications. In group B the Atlanta criteria were used to define severity. The variables analyzed were: age, gender, etiology, APACHE II, leukocytes, bicarbonate, fluid collections and necrosis on computed tomography, surgical treatment and mortality. RESULTS: Seventy-one patients were classified as severe, 24 in group A and 47 in group B. The mean APACHE II in groups A and B were 10.7 +/- 3.5 and 9.3 +/- 4.5, respectively. Necrosis was seen in 12 patients (50%) in group A and in 21 patients (44.7%) in group B. Half of the patients in group A and two (4.3%) in group B underwent to pancreatic interventions. Mortality reached 45.8% in group A and 8.5% in group B. CONCLUSION: A specific approach and a prospective protocol can change the results in the treatment of patients with severe acute pancreatitis.

Changes in the management of patients with severe acute pancreatitis / Mudanças no manejo de doentes com pancreatite aguda grave

BACKGROUND: Severe acute pancreatitis is present in up to 25 percent of patients with acute pancreatitis, with considerable mortality. Changes in the management of acute pancreatitis in the last 2 decades contributed to reduce the mortality. AIM: To show the evolution in the management of severe acute pancreatitis, comparing two different approaches. METHODS: All patients with severe acute pancreatitis from 1999 to 2005 were included. We compared the results of a retrospective review from 1999 to 2002 (group A) with a prospective protocol, from 2003 to 2005 (group B). In group A severe pancreatitis was defined by the presence of systemic or local complications. In group B the Atlanta criteria were used to define severity. The variables analyzed were: age, gender, etiology, APACHE II, leukocytes, bicarbonate, fluid collections and necrosis on computed tomography, surgical treatment and mortality. RESULTS: Seventy-one patients were classified as severe, 24 in group A and 47 in group B. The mean APACHE II in groups A and B were 10.7 ± 3.5 and 9.3 ± 4.5, respectively. Necrosis was seen in 12 patients (50 percent) in group A and in 21 patients (44.7 percent) in group B. Half of the patients in group A and two (4.3 percent) in group B underwent to pancreatic interventions. Mortality reached 45.8 percent in group A and 8.5 percent in group B. CONCLUSION: A specific approach and a prospective protocol can change the results in the treatment of patients with severe acute pancreatitis.

RACIONAL: A pancreatite aguda grave está presente em até 25 por cento dos doentes com pancreatite aguda, com mortalidade considerável. Mudanças no tratamento da pancreatite aguda nas últimas duas décadas contribuíram para a redução da mortalidade destes doentes. OBJETIVO: Mostrar a evolução do manejo da pancreatite aguda, comparando duas diferentes abordagens. MÉTODOS: Todos os doentes com pancreatite aguda grave de 1999 a 2005 do Serviço de Emergência da Santa Casa de São Paulo, SP, foram incluídos. Os resultados de uma revisão retrospectiva de 1999 para 2002 (grupo A) foram comparados com um protocolo prospectivo, de 2003 para 2005 (grupo B). No grupo A, a pancreatite grave era definida pela presença de complicações sistêmicas ou locais. No grupo B os critérios de Atlanta foram utilizados para definir a gravidade. As variáveis analisadas foram: idade, sexo, etiologia, APACHE II, leucócitos, bicarbonato, coleções e necrose na tomografia, tratamento cirúrgico e mortalidade. RESULTADOS: Setenta e um doentes foram classificados como graves, 24 no grupo A e 47 no grupo B. A média do APACHE II nos grupos A e B foram 10,7 ± 3,5 e 9,3 ± 4,5, respectivamente. A necrose foi vista em 12 doentes (50 por cento) no grupo A e em 21 doentes (44,7 por cento) no grupo B. Metade dos doentes no grupo A e dois (4,3 por cento) no grupo B foram submetidos a operação pancreática. A mortalidade foi de 45,8 por cento no grupo A e 8,5 por cento no grupo B. CONCLUSÃO: Uma abordagem específica e um protocolo prospectivo podem mudar os resultados no tratamento de doentes com pancreatite aguda grave.

Avaliação de complicações relacionadas à CPRE em pacientes com suspeita de coledocolitíase / Evaluation of ERCP-related morbidity in patients with choledocholithiasis suspicion

OBJETIVO: Determinar os fatores preditivos de complicações da colangio-pancreatografia retrógrada endoscópica (CPRE) nos doentes com suspeita diagnóstica de coledocolitíase. MÉTODO: Os dados foram coletados retrospectivamente durante o período de agosto de 1999 a janeiro 2005. Foram incluídos os doentes com suspeita diagnóstica de coledocolitíase submetidos à CPRE internados na Santa Casa de Misericórdia de São Paulo. Os doentes com neoplasia de vias biliares ou de pâncreas foram excluídos. Foram avaliados: o sucesso do procedimento, as complicações como pancreatite, sangramento, colangite, perfuração, vômitos, hiperamilasemia e em quais situações estas complicações se desenvolveram. Os testes t de Student, Qui-quadrado e o teste exato de Fisher foram empregados para análise estatística, considerando-se p< 0,05 como significativo. RESULTADOS: Cento e setenta oito doentes foram incluídos, sendo 52 homens e 126 mulheres com média etária de 54,3 + 19,3. A CPRE confirmou o diagnóstico de coledocolitíase em 124 doentes (69,7 por cento), obtendo sucesso no tratamento endoscópico em 92 casos (74,2 por cento). As complicações foram detectadas em 19 doentes (10,7 por cento), com seis casos de pancreatite aguda (3,4 por cento), quatro (2,2 por cento) que tiveram sangramento durante o procedimento endoscópico, dois (1,1 por cento) doentes que desenvolveram colangite, um (0,6 por cento) com perfuração duodenal, quatro (2,2 por cento) com vômitos sem pancreatite e dois (1,1 por cento) com complicações clinicas. A cateterização do ducto pancreático durante a realização do procedimento endoscópico esteve associada com o desenvolvimento de pancreatite aguda (p=0,004). CONCLUSÃO: A cateterização do pâncreas durante a CPRE constituiu um fator preditivo para o desenvolvimento de pancreatite aguda pós-CPRE.

BACKGROUND: To determine the predictors of complications resulting from endoscopic retrograde cholangiopancreatography (ERCP) in patients with choledocholithiasis. METHODS: Data were retrospectively collected from August 1999 to January 2005. Patients with clinical diagnosis of choledocholithiasis were included. Patients with tumours of the biliary tree or pancreas were excluded. The authors evaluated the procedure success and the risk factors associated with post-ERCP complications such as acute pancreatitis, hemorrhage, cholangitis, perforation, vomits and hyperamylasemia, and their association with the procedures. Student's t test, the Chi-square and the Fisher exact test were applied to the statistical analysis, considering p< 0.05 as significant. RESULTS: There were 178 patients (52 men and 156 women, mean age 54.3 + 19.3) included in the analysis. Choledocholithiasis was found in 124 patients (69.7 percent) and the sucess rate of the procedure was 74.2 percent (92 patients). Post-ERCP complications occurred in 19 patients (10.7 percent). Six patients (3.4 percent) had acute pancreatitis, four had hemorrhage from the papilla (2.2 percent), two had cholangitis (1.1 percent), one had duodenal perforation (0.6 percent), and other four had vomiting without pancreatitis (2.2 percent). Two patients had other clinical complications. The main pancreatic duct catheterization was identified as a risk factor for the development of acute pancreatitis after ERCP (p=0,004). CONCLUSION: Pancreatic duct catheterization during ERCP significantly increases the risk of acute pancreatitis post-ERCP.