Assessment of severity of acute pancreatitis over time.

In recent years there has been an increase in the incidence of acute pancreatitis worldwide. In spite of efforts to improve the treatment and care of patients with acute pancreatitis, to develop imaging investigations and interventional diagnostic and treatment techniques and to facilitate patients' access to them, acute pancreatitis continues to be associated with significant mortality and morbidity, and the treatment of patients suffering from this disease entails significant costs for healthcare systems. Researchers are in a permanent quest to get to a global consensus for stratifying the severity of acute pancreatitis. We need this in order to offer the proper management for each patient diagnosed with this condition and to improve hospital and health system strategies. Over the years, it has been attempted to develop algorithms to support a swift assessment of patients with acute pancreatitis with a prediction of disease severity as close to reality as possible for optimal management. This has led to the development of classifications of severity and severity scores. These require a permanent updating to keep up with the technical and technological developments involved in investigating and treating the patient and encompassing the most recent studies. The goal of this paper is to go through these classifications and scores, emphasizing factors that should be taken into account, and reflecting upon their utility and upon the necessity of improving them.

Prospective Validation of a Decision Tree Model for Prediction of Severity in Acute Pancreatitis.

BACKGROUND: Early identification of severe acute pancreatitis is important for early stratification, goal directed fluid therapy, rationalizing level of care to improve outcome. Various clinical, laboratory and imaging scoring system has been used to identify severe acute pancreatitis with variable results. Recently a decision tree model was proposed using serum creatinine, serum lactate dehydrogenase and oxygenation index to predict severe acute pancreatitis. This system is easy and usable at our centre. Hence, we conducted the study to validate the decision tree model prospectively. METHODS: Patients admitted with a diagnosis of acute pancreatitis were included in the study. Decision tree model was used to identify patients at high and low risk for severe acute pancreatitis. Sensitivity and specificity were calculated for prediction of the decision tree model. RESULTS: Fifty-three patients were included in the study. Fourty-one (77.4 %) patients with mild acute pancreatitis, five (9.4 %) patients had moderately severe pancreatitis and seven (13.2 %) patients had severe acute pancreatitis. Sensitivity and specificity of decision tree model to predict severity of pancreatitis was 97.83%(95 % CI - 88.47% to 99.94%) and 71.43 % % (95 % CI - 29.04% to 96.33%) respectively with positive and negative predictable value of 95.74 % % (95 % CI - 87.45% to 98.64%) and 83.33 % % (95 % CI - 40.49% to 97.35%) respectively. CONCLUSIONS: Decision tree model with serum creatinine, lactate dehydrogenase, and oxygenation index is an easy and useful tool to predict patients at high risk of developing severe acute pancreatitis.

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis.

BACKGROUND & AIMS: The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies. METHODS: The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included. RESULTS: Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis. CONCLUSION: The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Early diagnosis and severity assessment of acute pancreatitis (AP) using MR elastography (MRE) with spin-echo echo-planar imaging.

PURPOSE: To evaluate the accuracy of magnetic resonance elastography (MRE) in comparison to contrast-enhanced computed tomography (CE-CT) for early diagnosis and prediction of severity in acute pancreatitis (AP). MATERIALS AND METHODS: This cross-sectional prospective study included 76 patients with suspected AP who underwent both CE-CT and 3.0T MRE within 24 hours of hospital admission. Pancreatic stiffness, CT severity index (CTSI), Acute Physiology and Chronic Health Evaluation (APACHE)-II, and Bedside Index for Severity in AP (BISAP) scores were comparatively evaluated using data from the first 24 hours of admission, and diagnosis and severity of AP were confirmed according to the revised Atlanta Classification (2012). The accuracy of MRE for predicting disease severity was compared with that of CE-CT and the clinical scoring systems using area under the receiver-operating curve (AUC) analysis. RESULTS: AP was confirmed in 56/76 patients (73.7%). Pancreatic stiffness values of >1.47 kPa showed significantly better diagnostic performance than CE-CT (AUC: 0.993 vs. 0.818, P < 0.001) along with greater sensitivity (96.4% vs. 78.6%, P = 0.006) and accuracy (96.1% vs. 81.6%, P = 0.007). Ten patients (10/76; 13.2%) had clinically severe AP. The accuracy of pancreatic stiffness >2.47 kPa was comparable to that of the CTSI, APACHE-II and BISAP scores for predicting severe AP (accuracy = 85.5%, 75.0%, 88.2%, and 78.9%, respectively). The pairwise comparisons were not significant after Bonferroni correction (P < 0.008 [0.05/6]), with P values of 0.008 (MRE vs. CTSI), 0.823 (MRE vs. APACHE-II) and 0.414 (MRE vs. BISAP). CONCLUSION: Early MRE is a useful, noninvasive method for both diagnosis and early severity assessment of AP. We recommend MRE at hospital admission for initial evaluation of AP. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1311-1319.

[Diagnostic value of integral scoring systems in assessing the severity of acute pancreatitis and patient's condition].

OBJECTIVE: The aim of the study was to evaluate the diagnostic value of specific and nonspecific scoring systems Tolstoy-Krasnogorov score, Ranson, BISAP, Glasgow, MODS 2, APACHE II and CTSI, which used at urgent pancreatology for estimation the severity of acute pancreatitis and status of patient. METHODS: 1550 case reports of patients which had inpatient surgical treatment at Road clinical hospital at the station Krasnoyarsk from 2009 till 2013 were analyzed. Diagnosis of severe acute pancreatitis and its complications were determined based on anamnestic data, physical exami- nation, clinical indexes, ultrasonic examination and computed tomography angiography. Specific and nonspecific scores (scoring system of estimation by Tolstoy-Krasnogorov, Ranson, Glasgow, BISAP, MODS 2, APACHE II, CTSI) were used for estimation the severity of acute pancreatitis and patient's general condition. Effectiveness of these scoring systems was determined based on some parameters: accuracy (Ac), sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Most valuables score for estimation of acute pancreatitis's severity is BISAP (Se--98.10%), for estimation of organ failure--MODS 2 (Sp--100%, PPV--100%) and APACHE II (Sp--100%, PPV--100%), for detection of pancreatonecrosis sings--CTSI (Sp--100%, NPV--100%), for estimation of need for intensive care--MODS 2 (Sp--100%, PPV--100%, NPV--96.29%) and APACHE II (Sp--100%, PPV--100%, NPV--97.21%), for prediction of lethality--MODS 2 (Se-- 100%, Sp--98.14%, NPV--100%) and APACHE II (Se--95.00%, NPV-.99.86%). CONCLUSION: Most effective scores for estimation of acute pancreatitis's severity are Score of estimation by Tolstoy-Krasnogorov, Ranson, Glasgow and BISAP Scoring systems MODS 2, APACHE I high specificity and positive predictive value allow using it at clinical practice.

[Pathophysiology and Assessment of IgG4-Related Disease--Focus on Autoimmune Pancreatitis].

IgG4-related disease is well-known, and while the functions of cytokines which affect IgG4 production are being clarified, it remains unclear what causes it. There are many clinicopathological characteristics of IgG4-related disease and, therefore, comprehensive criteria are used for diagnosis. Notably, histopathological findings are the most important of these, with which we cannot make a definite diagnosis. The model disease of an IgG4-related disease is autoimmune pancreatitis (AIP). Currently, AIP is classified into type 1 (AIP1) and type 2 (AIP2). AIP1 is IgG4-related while AIP2 is not. AIP1 sometimes has localized mass formation, making it difficult to distinguish between AIP1 and pancreatic cancer. Thus, upon biochemical and immunological examination, the IgG4 level is the most useful for the diagnosis, although the levels of IL-2R, ß2MG, C4, and monoclonal rheumatoid factor are also useful for the assessment of disease. In addition, histopathological findings are also important to diagnose AIP1. Typical AIP1 cases show lymphoplasmacytic infiltration including IgG4-positive plasma cells with storiform fibrosis. A careful analysis of cases with the typical features of IgG4-related disease will lead to the elucidation of the mechanism behind IgG4-related disease.

[Assessment and treatment of acute pancreatitis. Position document of the Catalan Society of Gastroenterology, Catalan Society of Surgery and Catalan Society of the Pancreas]. / Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees.

The incidence of acute pancreatitis (AP) is increasing. AP is one of the gastrointestinal diseases that most frequently requires hospital admission in affected individuals. In the last few years, considerable scientific evidence has led to substantial changes in the medical and surgical treatment of this disease. New knowledge of the physiopathology of AP indicates that its severity is influenced by its systemic effects (organ failure), especially if the disease is persistent, and also by local complications (fluid collections or necrosis), especially if these become infected. Treatment should be personalized and depends on the patient's clinical status, the location of the necrosis, and disease stage.

[Results of dynamic assessment of melatonin receptor expression in lymphocytes in patients with acute mild and severe pancreatitis].

The authors present results of the investigation of melatonin receptors expression in lymphocytes in dynamics in 102 patients with acute pancreatitis of mild and severe form and in 50 volunteers. A correlated analysis was made between obtained results of laboratory and instrumental researches and clinical course of acute pancreatitis. The decrease of MT1 receptors expression was noted on 25% in patients with acute pancreatitis. The decline of MT2 receptors expression was observed on 40% of patients with acute severe pancreatitis and in a case of acute mild pancreatitis--on 15.5%, respectively. Values of MT1 and MT2 expression were equal between healthy volunteers. The decline of MT2 expression was a prognostic unfavourable sign. Obtained results of dynamic expression assessment of MT-receptors were presented as MT2/MT1 indices. Given index didn't change during disease, because of this, the index could be used as a prognostic development marker of destructive form of acute pancreatitis at the moment of patient's admission to hospital. Mean values of MT2/MT1 were determined for the purpose of universalization of used method (1.13 +/- 0.09 for mild form and 0.81 +/- 0.09 for severe form of acute pancreatitis, respectively).

Outcome assessment in acute pancreatitis patients.

Early diagnosis and severity evaluation in patients with acute pancreatitis (AP) are very important due to its potential morbidity and mortality. Several clinical, laboratory, and radiologic factors, and many scoring systems have been proposed for outcome prediction. Although the Ranson and Acute Physiology and Chronic Health Evaluation II scoring systems have been widely used for decades, the cumbersome components partly limit their predictability. Recently, the Bedside Index for Severity in AP scoring system and series blood urea nitrogen changes, which are simple and convenient to evaluate within 24 hours after admission, have been validated for accuracy by several large-cohort studies. The presence of organ failure and systemic inflammatory response syndrome are also helpful to evaluate the severity of AP. Herein we review recent advances of the predictive methods for AP to provide an up-to-date perspective on outcome assessment of AP.

What have we learned about acute pancreatitis in children?

Pediatric pancreatitis has received much attention during the past few years. Numerous reports have identified an increasing trend in the diagnosis of acute pancreatitis in children and key differences in disease presentation and management between infants and older children. The present review provides a brief, evidence-based focus on the latest progress in the clinical field. It also poses important questions for emerging multicenter registries to answer about the natural history and management of affected children with pancreatitis.

Recent advances in the epidemiology of alcoholic pancreatitis.

Clinical observation has defined the medical profile of alcoholic pancreatitis, but its low incidence and prevalence has limited characterizing the disease at a population level, the contribution of environmental exposures, and a clear picture of its natural history. Recent studies have defined the impact of alcohol use and smoking on disease risk, and a threshold for alcohol consumption has been identified. Recurrent attacks of acute pancreatitis have been linked with continued alcohol consumption, and aggressive alcohol intervention has been shown to decrease recurrence. Progression from alcoholic acute pancreatitis to chronic pancreatitis is now believed to occur infrequently, and factors associated with progression have been identified. Alcoholic pancreatitis reduces lifespan in these patients, and the economic impact of pancreatitis is substantial. Efforts are needed to increase awareness of the impact of alcohol consumption and smoking on risk for pancreatitis and the benefits of cessation for primary and secondary prevention.

Dyslipidaemic pancreatitis clinical assessment and analysis of disease severity and outcomes.

INTRODUCTION: The relationship between pancreatitis and dyslipidaemia is unclear. PATIENTS AND METHODS: Admissions with acute pancreatitis were prospectively evaluated. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths was made in relationship to the lipid profiles. RESULTS: From June 2001 to May 2005, there were 230 admissions. The pancreatitis was associated with alcohol (63%), gallstones (18%), idiopathic (9%) and isolated dyslipidaemia (10%). Dyslipidaemia was significantly different between the two predominant race groups: Indian 50.5% and African 17.9% (p < 0.000017). Seventy-eight (34%) had associated dyslipidaemia and 152 (66%) were normolipaemic at admission. The average body mass index was higher in the dyslipidaemic group (27 +/- 6) than in the normolipaemic group (24.5 +/- 6.20; p = 0.004). The mortality rate was similar between the dyslipidaemic and normolipaemic patients (10 and 8%, respectively) and unrelated to race (p = 0.58). The 9 deaths in the dyslipidaemic group occurred in those with persistent hypertriglyceridaemia irrespective of its level (p = 0.003). CONCLUSION: Dyslipidaemic pancreatitis was more common in the Indian ethnic group. Adverse outcomes in those with dyslipidaemia were predominantly associated with hypertriglyceridaemia.

[Ultrasonographic assessment of chronic pancreatitis severity. Pancreatic index].

AIM: To introduce the pancreatic index assessing severity of chronic pancreatitis (CP). MATERIAL AND METHODS: Ultrasonography was made in 28 patients with clinically documented diagnosis of CP. A total of 6 groups of ultrasonographic signs served the basis for calculation of scores for a complex formalized semiquantitative criterion--the pancreatic index (PI). Ultrasonographic signs--the size of the head, calcinates, structure, maximal size of the ductus pancreaticus, pseudocysts, etc. were assessed in scores from 1 to 3. Severity of the disease was classified according to total PI. RESULTS: The following correlation was found between severity of CP and the PI: in mild CP--57%, in moderate CP--71%, in severe CP--66%. CONCLUSION: Ultrasonographic PI objectively evaluates severity of CP course.

JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis.

This article addresses the criteria for severity assessment and the severity scoring system of the Ministry of Health and Welfare of Japan; now the Japanese Ministry of Health, Labour, and Welfare (the JPN score). It also presents data comparing the JPN score with the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson score, which are the major measuring scales used in the United States and Europe. The goal of investigating these scoring systems is the achievement of earlier diagnosis and more appropriate and successful treatment of severe or moderate acute pancreatitis, which has a high mortality rate. This article makes the following recommendations in terms of assessing the severity of acute pancreatitis: (1) Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis (Recommendation A). (2) Assessment by a severity scoring system (JPN score, APACHE II score) is important for determining treatment policy and identifying the need for transfer to a specialist unit (Recommendation A). (3) C-reactive protein (CRP) is a useful indicator for assessing severity (Recommendation A). (4) Contrast-enhanced computed tomography (CT) scanning and contrast-enhanced magnetic resonance imaging (MRI) play an important role in severity assessment (Recommendation A). (5) A JPN score of 2 or more (severe acute pancreatitis) has been established as the criterion for hospital transfer (Recommendation A). (6) It is preferable to transfer patients with severe acute pancreatitis to a specialist medical institution where they can receive continuous monitoring and systemic management.

Applicability of disseminated intravascular coagulation parameters in the assessment of the severity of acute pancreatitis.

OBJECTIVES: To evaluate the clinical applicability of the determination of disseminated intravascular coagulation (DIC) parameters in acute pancreatitis. METHODS: The subjects for this study were 139 consecutive patients with acute pancreatitis. DIC parameters were assessed at the initial observation of these patients. RESULTS: The levels of the DIC parameters at admission were significantly associated with the severity and the prognosis of acute pancreatitis. Antithrombin III (AT-III), fibrin/fibrinogen degradation products-E, platelet count, D-dimer, and thrombin-AT-III complex at admission showed better area under the receiver operating characteristics curve values compared with C-reactive protein. An AT-III value of 69% at admission was the best cut-off value to predict fatal outcome (sensitivity, 81%; specificity, 86%). CONCLUSIONS: The aggravated coagulation parameters predict a fatal outcome in patients with acute pancreatitis. AT-III level (<69%) was the most accurate marker for poor outcome of acute pancreatitis at admission.

Iced versus room temperature injectate for assessment of cardiac output, intrathoracic blood volume, and extravascular lung water by single transpulmonary thermodilution.

PURPOSE: To assess the accuracy of iced versus room (RT) temperature single transpulmonary thermodilution (STPD) measurements for cardiac output, intra-thoracic blood, volume and extravascular lung water. MATERIALS AND METHODS: We studied 15 critically ill patients in a surgical intensive care unit with sepsis/septic shock (n = 8), pancreatitis (n = 2), acute liver failure (n = 2), orthotopic liver transplantation (n = 2) and lung resection (n = 1). All patients were sedated and mechanically ventilated. A 4-French femoral arterial catheter was inserted into each patient and connected to the pulse contour computer system (PiCCO). The pulse contour computer was then consecutively calibrated by triplicate STPD with 20 mL of RT and iced saline solution. The measurements with RT injectate were performed with a special in-line sensor adapted for measurement with RT injectate. All measurements were completed in less than 10 min. RESULTS: A total of 144 measurements were carried out. Linear regression analysis revealed good correlation between the two methods [r = 0.95; r = 0.91 and r = 0.97 for iced v RT cardiac index (CI), intrathoracic blood volume index (ITBVI) and extravascular lung water index (ELWI) respectively]. The bias +/- 2 * standard deviation of difference was -0.2 +/- 0.7 L/min/m2 for CIIT v CIRT; -4,9 +/- 194 mL/m2 for ITBVIIT v ITBVIRT and -0.535 +/- 1,5 mL/kg for ELWIIT v ELWIRT. CIRT and ELWIRT were measured slightly higher compared to IT injectate (P <.05). CONCLUSIONS: CI, ITBVI, and ELWI assessed by STPD with RT injectate are well correlated with measurements by iced injectates. According to our results room temperature injectates can be used in critically ill patients for assessment of CI, ITBVI and ELWI, which is more convenient for both the patients and medical staff and is also less expensive.

Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis.

BACKGROUND & AIMS: This study aimed to compare the accuracy of magnetic resonance imaging (MRI) with computed tomography (CT) in assessing acute pancreatitis (AP) and to explore the correlation between MRI findings and clinical outcome. METHODS: Patients with AP were investigated by contrast-enhanced CT and MRI on admission and 7 and 30 days thereafter. MRI was performed with intravenous secretin and contrast medium. Balthazar's grading system was used to measure CT and MRI severity indices (CTSI and MRSI, respectively). RESULTS: Thirty-nine patients (median age, 47 years; range, 15-86) were studied. AP was of biliary etiology in 19 patients (49%). On admission, AP was assessed clinically as severe in 7 patients (18%). A strong correlation was demonstrated between CTSI and MRSI on admission and 7 days later. MRSI on admission correlated with the following: the Ranson score, C-reactive protein levels 48 hours after admission, duration of hospitalization, and clinical outcome regarding morbidity, including local and systemic complications. Considering the Ranson score as the gold standard, MRI detected severe AP with 83% (58-96, 95% CI) sensitivity, 91% (68-98) specificity vs. 78% (52-93) and 86% (63-96) for CT. Magnetic resonance cholangiopancreatography after i.v. secretin injection showed pancreatic duct leakage in 3 patients (8%). CONCLUSIONS: MRI is a reliable method of staging AP severity, has predictive value for the prognosis of the disease, and has fewer contraindications than CT. It can also detect pancreatic duct disruption, which may occur early in the course of AP.