Risk factors of infected pancreatic necrosis secondary to severe acute pancreatitis.

BACKGROUND: Severe acute pancreatitis (SAP) remains a clinical challenge with considerable morbidity and mortality. An early identification of infected pancreatic necrosis (IPN), a life-threatening evolution secondary to SAP, is obliged for a more preferable prognosis. Thus, the present study was conducted to identify the risk factors of IPN secondary to SAP. METHODS: The clinical data of patients with SAP were retrospectively analyzed. Univariate and multivariate logistic regression analyses were sequentially performed to assess the associations between the variables and the development of IPN secondary to SAP. A receiver operating characteristic (ROC) curve was created for each of the qualified independent risk factors. RESULTS: Of the 115 eligible patients, 39 (33.9%) progressed to IPN, and the overall in-hospital mortality was 11.3% (13/115). The early enteral nutrition (EEN) (P=0.0092, OR=0.264), maximum intra-abdominal pressure (IAP) (P=0.0398, OR=1.131) and maximum D-dimer level (P=0.0001, OR=1.006) in the first three consecutive days were independent risk factors associated with IPN secondary to SAP. The area under ROC curve (AUC) was 0.774 for the maximum D-dimer level in the first three consecutive days and the sensitivity was 90% and the specificity was 58% at a cut-off value of 933.5 µg/L; the AUC was 0.831 for the maximum IAP in the first three consecutive days and the sensitivity was 95% and specificity was 58% at a cut-off value of 13.5 mmHg. CONCLUSIONS: The present study suggested that the maximum D-dimer level and/or maximum IAP in the first three consecutive days after admission were risk factors of IPN secondary to SAP; an EEN might be helpful to prevent the progression of IPN secondary to SAP.

The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis.

BACKGROUND: The Atlanta criteria for acute pancreatitis (AP) has been revised recently. This study was to evaluate its practical value in classification of AP, the severity assessment and management. METHODS: The clinical features, severity classification, outcome and risk factors for mortality of 3212 AP patients who had been admitted in Ruijin Hospital from 2004 to 2011 were analyzed based on the revised Atlanta criteria (RAC) and the original Atlanta criteria (OAC). RESULTS: Compared to the OAC group, the incidence of severe acute pancreatitis (SAP) was decreased by approximately one half (13.9% vs 28.2%) in the RAC group. The RAC presented a lower sensitivity but higher specificity, and its predictive value for severity and poor outcome was higher than those of the OAC. The proportion of SAP diagnosis and ICU admission in the early phase in the RAC group was significantly lower than that in the OAC group (P<0.05). Based on the RAC, the risk factors for death among SAP patients were older age, high CT severity index (CTSI), renal failure, cardiovascular failure, acute necrotic collection and walled-off necrosis. Compared to the OAC, the acute physiology and chronic health evaluation II (APACHE II) score, Ranson score, idiopathic etiology, respiratory failure and laparotomy debridement were not risk factors of death in contrast to walled-off necrosis. Interestingly, hypertriglyceridemia-related SAP had good outcomes in both groups. CONCLUSIONS: The RAC showed a higher predictive value for severity and poorer outcome than the OAC. However, the RAC resulted in fewer ICU admissions in the early phase due to its lower sensitivity for diagnosis of SAP. Among SAP cases, older age, high CTSI, renal and cardiovascular failure, complications of acute necrotic collection and walled-off necrosis were independent risk factors for mortality.

Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment.

Walled-off necrosis (WON) is a relatively new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 1 of this statement focused on the epidemiology, diagnosis, and timing of intervention.

Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis.

OBJECTIVE: To develop a model for the early prediction of severe acute pancreatitis based on the revised Atlanta classification of acute pancreatitis. METHODS: Clinical data of 1308 patients with acute pancreatitis (AP) were included in the retrospective study. A total of 603 patients who were admitted to the hospital within 36 hours of the onset of the disease were included at last according to the inclusion criteria. The clinical data were collected within 12 hours after admission. All the patients were classified as having mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) based on the revised Atlanta classification of acute pancreatitis. All the 603 patients were randomly divided into training group (402 cases) and test group (201 cases). Univariate and multiple regression analyses were used to identify the independent risk factors for the development of SAP in the training group. Then the prediction model was constructed using the decision tree method, and this model was applied to the test group to evaluate its validity. RESULTS: The decision tree model was developed using creatinine, lactate dehydrogenase, and oxygenation index to predict SAP. The diagnostic sensitivity and specificity of SAP in the training group were 80.9% and 90.0%, respectively, and the sensitivity and specificity in the test group were 88.6% and 90.4%, respectively. CONCLUSIONS: The decision tree model based on creatinine, lactate dehydrogenase, and oxygenation index is more likely to predict the occurrence of SAP.

Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study.

BACKGROUND & AIMS: The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality. METHODS: We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs. RESULTS: From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality. CONCLUSIONS: In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.

Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography in 350 patients.

BACKGROUND: This prospective study has been conducted with the aim to assess the severity of acute pancreatitis. METHODS: The study included 350 consecutive patients with acute pancreatitis admitted over a period of five years. All these patients were subjected to detailed history and clinical examination and investigations to ascertain the diagnosis. The severity was assessed by contrast - enhanced computed tomography (CT). Data collected were tabulated and subjected to appropriate statistical analysis. RESULTS: On the basis of the CT Severity Index (CTSI), the severity of acute pancreatic was classified into Group A (mild), Group B (moderate), or Group C (severe). Group C patients had the most complications (in 77 [91.67%] patients), and Group A patients had the least (in 7 [6.25%] patients). Mortality was found to be highest among Group C (14 [16.67%] patients), indicating the severe nature of disease in these patients, while no mortality was noted in Group A patients. The mean duration of hospital stay of patients in Group A was 9.25 days, Group B 12.0 days and Group C 24.58 days. CONCLUSION: The use of contrast-enhanced computed tomography as a routine investigation in patients to predict a severe attack of acute pancreatitis early in the course of the disease decreases overall mortality and burden of disease.

Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy.

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

[Acute pancreatitis: advances in classification and assessment of severity].

Acute pancreatitis is an inflammatory disease of the pancreas. It has a wide range of clinical presentations, from a mild self-limiting disease to a severe with prolonged hospitalization, high morbidity of complications, and high mortality. It is very important to accurately assess the severity for AP in early phase. Various severity clinical and radiological scoring systems have been used for assessing the prognosis of acute pancreatitis. The purpose of this review is to introduce advances in classification and assessment of severity in acute pancreatitis.

Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis.

OBJECTIVES: Identification of patients at risk for severe disease early in the course of acute pancreatitis (AP) is an important step to guiding management and improving outcomes. A new prognostic scoring system, the bedside index for severity in AP (BISAP), has been proposed as an accurate method for early identification of patients at risk for in-hospital mortality. The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the "traditional" multifactorial scoring systems: Ranson's, Acute Physiology and Chronic Health Examination (APACHE)-II, and computed tomography severity index (CTSI) in predicting severity, pancreatic necrosis (PNec), and mortality in a prospective cohort of patients with AP. METHODS: Extensive demographic, radiographic, and laboratory data from consecutive patients with AP admitted or transferred to our institution was collected between June 2003 and September 2007. The BISAP and APACHE-II scores were calculated using data from the first 24 h from admission. Predictive accuracy of the scoring systems was measured by the area under the receiver-operating curve (AUC). RESULTS: There were 185 patients with AP (mean age 51.7, 51% males), of which 73% underwent contrast-enhanced CT scan. Forty patients developed organ failure and were classified as severe AP (SAP; 22%). Thirty-six developed PNec (19%), and 7 died (mortality 3.8%). The number of patients with a BISAP score of > or =3 was 26; Ranson's > or =3 was 47, APACHE-II > or =8 was 66, and CTSI > or =3 was 59. Of the seven patients that died, one had a BISAP score of 1, two had a score of 2, and four had a score of 3. AUCs for BISAP, Ranson's, APACHE-II, and CTSI in predicting SAP are 0.81 (confidence interval (CI) 0.74-0.87), 0.94 (CI 0.89-0.97), 0.78 (CI 0.71-0.84), and 0.84 (CI 0.76-0.89), respectively. CONCLUSIONS: We confirmed that the BISAP score is an accurate means for risk stratification in patients with AP. Its components are clinically relevant and easy to obtain. The prognostic accuracy of BISAP is similar to those of the other scoring systems. We conclude that simple scoring systems may have reached their maximal utility and novel models are needed to further improve predictive accuracy.

Serum adhesion molecules in acute pancreatitis: time course and early assessment of disease severity.

OBJECTIVES: To evaluate the adhesion molecule time course in the early phases of acute pancreatitis and to explore the usefulness of these proteins in assessing the severity of the disease. Fifteen consecutive acute pancreatitis patients (10 patients with the mild and 5 with the severe disease) admitted to the hospital within 6 hours after the onset of pain and 15 age- and sex-matched healthy subjects. METHODS: Vascular cell adhesion molecule 1, intercellular adhesion molecule 1, E-selectin, P-selectin, and L-selectin were quantified on hospital admission and for the following 2 days. RESULTS: Acute pancreatitis patients had vascular cell adhesion molecule 1 and P-selectin concentrations significantly lower and L-selectin concentrations significantly higher than the healthy subjects. Only E-selectin was significantly higher in severe than in mild disease (P = 0.029); a value of E-selectin ranging from 3.83 to 3.92 ng/mL was the best cutoff value for differentiating severe from mild acute pancreatitis (sensitivity: 60.0%, specificity: 90.0%, cases correctly classified: 80%). E-selectin and P-selectin entered the multivariate logistic regression analysis, and a score was calculated showing a sensitivity of 93.3% and a specificity of 86.7% in identifying the patients with severe pancreatitis. CONCLUSIONS: This score seems to be useful for the early assessment of the severity of acute pancreatitis.

Management of necrotizing pancreatitis: flexible approach depending on intra-operative assessment of necrosis.

INTRODUCTION: The surgical management of necrotizing pancreatitis (NP) has changed over the years. MATERIAL AND METHODS: Among 144 patients, 12.5% (n = 18) were treated conservatively and 87.5% (n = 126) underwent surgery. The choice of operative method depended on the intra-operative assessment of consistency and on the extent of necrosis. A group of 126 patients underwent necrosectomy, followed by laparostomy with open packing in 80% (n = 101) cases, drainage in 14% (n = 18) and continuous closed lavage in 6% (n = 7). RESULTS: Postoperative complications occurred in 42.8% (n = 54) of the patients who underwent the surgery. Hospital mortality rate over all patients was 18% and 20.6% (n = 26) in the group of patients who underwent the surgery. Mean hospital stay was 61 +/- 36 days. Patients managed conservatively (n = 18) were discharged without surgical intervention. In this group no complications or deaths were observed. CONCLUSION: Using the three different surgical techniques in the management of NP, depending on intra-operative assessment of necrosis, showed promising results. A flexible approach targeted at a single patient and tailored to the clinical course and intra-operative situation should be considered in the treatment of NP.

The usefulness of laboratory tests in the early assessment of severity of acute pancreatitis.

Acute pancreatitis is a disorder that affects approximately 200,000 individuals in the U.S. annually. While most cases are mild, up to 30% of patients will have a complicated course with prolonged hospitalization and significant morbidity and mortality. Early institution of several therapeutic interventions, such as enteral nutrition, prophylactic antibiotics, endoscopic retrograde cholangiopancreatography (ERCP) and intensive care monitoring, have been shown to decrease the morbidity associated with severe acute pancreatitis. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe pancreatitis has remained poor over the years, thus leading to a delay in the institution of such treatments. Researchers have focused on markers that might improve upon clinical prediction alone. While data have shown the predictive value of tools such as Ranson's and Glasgow's criteria, C-reactive protein (CRP) and the APACHE score, their application in clinical practice has been limited by a time delay of at least 48 h in the former two and by being cumbersome in the latter. Thus, our focus is to critically appraise the evidence available for various biochemical markers in their ability to distinguish mild and severe acute pancreatitis early and more accurately than currently available tools.

[Acute pancreatitis--clinical and technical laboratory diagnostic and prognostic assessment]. / Akute Pankreatitis--klinische und labortechnische Diagnose- und Prognosestellung.

The incidence of acute pancreatitis within 100,000 inhabitants a year differs between 5 (Bristol) and 80 (USA). Even though the diagnosis of pancreatitis has become easier by the measurement of specific pancreatic enzymes there are still 30-40% of the fatal cases which are first diagnosed at autopsy. It is of utmost importance to assess the diagnosis and the severity of acute pancreatitis in the beginning to identify those patients with severe or necrotising disease who benefit from an early initiated intensive care therapy. Additionally, in view of new therapeutical concepts (e.g. antibiotic therapy in severe forms) and for the evaluation of new drugs, patients should be staged into mild and severe disease as early as possible. In most cases it is not possible to assess the severity clinically on hospital admission. Up to now the "gold standard" are imaging procedures (contrast-enhanced CT and MRI) which should be reserved for the severe cases to estimate the extent of pancreatic necrosis. The ideal predictor in blood or in urine should be objective, reliable, inexpensive, easy to measure, widely available, sensitive and specific. There are a variety of mediators of the "systemic inflammatory response syndrome" which are elevated in this disease (C-reactive protein, antiproteases, enzyme activation peptides like trypsinogen activation peptide (TAP) and carboxypeptidase B activation peptide (CAPAP), PMN-elastase, complement factors, chemokines and interleukins and others). Among all these mediators, C-reactive protein is the parameter best analysed. It has to be taken into account that it is not specific for AP and it's highest efficacy is reached after > 48 hours after the onset of disease. However, because usually a certain time elapses (approximately 24-48 hours) until patients are hospitalised the time delay seems not to a major disadvantage.

Assessment and treatment of severe pancreatitis. Protease inhibitor.

From the theoretical point of view, antiproteolytic therapy would seem to be the rationale for acute pancreatitis management. Unfortunately, clinical human trials studying the role of antiproteases in the treatment of acute pancreatitis differ in several respects in terms of their basic design. As a consequence, any form of homogeneous analysis of the reported data as a whole is impossible. Considering the data emerging from a meta-analysis of five trials a rational use of antiproteases may result in a reduction of complications requiring surgery and of patient management costs only in selected cases, meaning by that severe and necrotic forms. As regards presumptive applications, over 400 patients were prospectively tested versus placebo in a double-blind trial with the aim of preventing acute pancreatitis after ERCP. The complication incidence was significantly lower among the pretreated patients; anyway, also in this field of protease inhibitor clinical application it is necessary to identify the patients with the greatest risk to develop post-ERCP acute pancreatitis. In conclusion, antiproteases can still play a role when given prophylactically or when used in the very early phases of the disease; moreover a 'multiple drugs approach' (including, for example, suitable antibiotics) seems to represent nowadays the most modern and rational treatment of acute pancreatitis.