DIFFERENT SCORING SYSTEMS IN ACUTE ALCOHOLIC PANCREATITIS: WHICH ONE TO FOLLOW? AN ONGOING DILEMA.

BACKGROUND: Acute pancreatitis is a common disorder in medical practice. In recent times, management has changed drastically with majority of decisions like intravenous antibiotics, negative suction with Ryle's tube and surgical interventions like necrosectomy etc based on severity of the disease. There are different scores in use to assess severity of disease but the relative efficacy has remained a debatable subject. OBJECTIVE: The present study was thus done to investigate the predictive accuracy of different scoring systems in acute pancreatitis. METHODS: Fifty patients of acute pancreatitis admitted in medicine ward of Pt. B.D. Sharma PGIMS, Rohtak, India, were taken for study after fulfilling eligibility criteria. These patients were investigated at admission and followed up prospectively. The severity of pancreatitis was classified for each of these patients as per Revised Atlanta System of Classification. Commonly used scoring systems pertaining to acute pancreatitis, viz, BISAP, Ranson, APACHE II and modified computed tomography severity index (CTSI) were calculated. Subsequently these scores were then correlated with severity, presence of organ failure, occurrence of local complications and final outcome of the patients. RESULTS: Out of 50 patients, etiology was chronic alcohol intake in all but one with idiopathic pancreatitis. The mean age of the study population was 42.06±13.27 years. 32% of these patients had pancreatic necrosis, 40% had peripancreatic collections. 56% of them had mild acute pancreatitis, 24% had moderately severe acute pancreatitis, while 20% had severe acute pancreatitis. APACHE II had the highest accuracy in predicting severity, organ failure and fatal outcomes. As far as these parameters were concerned, the negative predictive values of BISAP score were also considerable. Modified CTSI score was accurate in predicting local complications but had limited accuracy in other predictions. CONCLUSION: APACHE II emerged as most reliable scoring system followed by BISAP and Ranson in management of the patients with acute pancreatitis. But in constraints of time and resources, even BISAP score with its significant negative predictive values served as a valuable tool for assessing and managing these patients.

Diferentes sistemas de pontuação na pancreatite alcoólica aguda: qual a seguir? Um dilema em curso / Different scoring systems in acute alcoholic pancreatitis: which one to follow? an ongoing dilema

ABSTRACT BACKGROUND: Acute pancreatitis is a common disorder in medical practice. In recent times, management has changed drastically with majority of decisions like intravenous antibiotics, negative suction with Ryle's tube and surgical interventions like necrosectomy etc based on severity of the disease. There are different scores in use to assess severity of disease but the relative efficacy has remained a debatable subject. OBJECTIVE: The present study was thus done to investigate the predictive accuracy of different scoring systems in acute pancreatitis. METHODS: Fifty patients of acute pancreatitis admitted in medicine ward of Pt. B.D. Sharma PGIMS, Rohtak, India, were taken for study after fulfilling eligibility criteria. These patients were investigated at admission and followed up prospectively. The severity of pancreatitis was classified for each of these patients as per Revised Atlanta System of Classification. Commonly used scoring systems pertaining to acute pancreatitis, viz, BISAP, Ranson, APACHE II and modified computed tomography severity index (CTSI) were calculated. Subsequently these scores were then correlated with severity, presence of organ failure, occurrence of local complications and final outcome of the patients. RESULTS: Out of 50 patients, etiology was chronic alcohol intake in all but one with idiopathic pancreatitis. The mean age of the study population was 42.06±13.27 years. 32% of these patients had pancreatic necrosis, 40% had peripancreatic collections. 56% of them had mild acute pancreatitis, 24% had moderately severe acute pancreatitis, while 20% had severe acute pancreatitis. APACHE II had the highest accuracy in predicting severity, organ failure and fatal outcomes. As far as these parameters were concerned, the negative predictive values of BISAP score were also considerable. Modified CTSI score was accurate in predicting local complications but had limited accuracy in other predictions. CONCLUSION: APACHE II emerged as most reliable scoring system followed by BISAP and Ranson in management of the patients with acute pancreatitis. But in constraints of time and resources, even BISAP score with its significant negative predictive values served as a valuable tool for assessing and managing these patients.

RESUMO CONTEXTO: A pancreatite aguda é uma desordem comum na prática médica. Nos últimos tempos, sua gestão mudou drasticamente com a maioria das decisões tomadas baseadas na gravidade da doença, como administração de antibióticos intravenosos, sucção negativa com o tubo de Ryle ou intervenções cirúrgicas como necrosectomia, etc. Há diferentes escores em uso para avaliar a gravidade da doença, mas a eficácia relativa manteve-se um assunto discutível. OBJETIVO: O presente estudo foi assim realizado para investigar a acurácia preditiva de diferentes sistemas de pontuação na pancreatite aguda. MÉTODOS: Foram selecionados 50 pacientes com pancreatite aguda admitidos na enfermaria de medicina de Pt. B.D. Sharma PGIMS, Rohtak, Índia, e foram considerados para estudo após o cumprimento dos critérios de elegibilidade. Estes pacientes foram investigados na admissão e seguidos prospectivamente. A severidade da pancreatitie foi classificada para cada um destes pacientes pelo sistema de classificação Atlanta revisado. Os sistemas de pontuação comumente usados pertencentes à pancreatite aguda, ou seja, BISAP, Ranson, APACHE II e CTSI modificado foram calculados. Posteriormente, esses escores foram correlacionados com a severidade, presença de falência de órgãos, ocorrência de complicações locais e desfecho final dos pacientes. RESULTADOS: Dos 50 pacientes, a ingestão crônica de álcool foi a etiologia em todos, exceto em um com pancreatite idiopática. A média de idade da população estudada foi de 42,6±13,27 anos. Destes pacientes, 32% apresentavam necrose pancreática, 40% apresentavam coleções peripancreáticas, 56% apresentavam pancreatite aguda leve, 24% apresentavam pancreatite aguda moderadamente grave, enquanto 20% apresentavam pancreatite aguda grave. O APACHE II teve maior precisão em prever a severidade, a falha do órgão e resultados fatais. No que diz respeito a esses parâmetros, os valores preditivos negativos do escore BISAP também foram consideráveis. A contagem modificada de CTSI foi exata em prever complicações locais, mas teve a exatidão limitada em outras predições. CONCLUSÃO: O APACHE II emergiu como o sistema de pontuação mais confiável seguido por BISAP e Ranson na gestão dos pacientes com pancreatite aguda. Mas em condicionantes do tempo e dos recursos, mesmo a Pontuação do BISAP com seus valores preditivos negativos significativos, serviu como uma ferramenta valiosa para avaliar e administrar esses pacientes.

Predictors of 90-day mortality in patients with severe alcoholic hepatitis: Experience with 183 patients at a tertiary care center from India.

BACKGROUND: Severe alcoholic hepatitis (AH) is not an uncommon indication for hospital admission in India. However, there is limited data from India on predictors of mortality in patients of severe AH. We analyzed the data on patients with severe AH admitted to our institute and compared various parameters and severity scores in predicting 90-day mortality. METHODS: In this prospective study, we analyzed patients with severe AH (defined as discriminant function ≥ 32) admitted from January 2015 to February 2017 to our institute. All patients were administered standard treatment according to various guidelines, and their 90-day mortality was determined. Various hematologic, biochemical factors, and severity scores were compared between survivors and patients who died. RESULTS: A total of 183 patients (98% males, median age 41 years [range 20-70 years]) were included in our study. The median model for end-stage liver disease (MELD) was 26 (15-40). Ascites were present in 83% and hepatic encephalopathy in 38%. Only 21 (12%) could be offered steroid therapy, due to contraindications in the remaining. By 90 days, only 103 (56%) patients survived while 80 (44%) died. All patients died due to progressive liver failure and its complications. On multivariate analysis, presence of ascites, hepatic encephalopathy, high bilirubin, low albumin, high creatinine, high INR, and low potassium independently predicted 90-day mortality. All the scores performed significantly in predicting 90-day mortality with no statistically significant difference between them. MELD score had a maximum area under the curve 0.76 for 90-day mortality. A combination of Child class and presence of acute kidney injury (creatinine ≥ 1.35) was good in predicting 90-day mortality. CONCLUSION: Our patients had severe AH characterized by a median MELD score of 26 and had a 90-day mortality of 44%. Most patients were not eligible to receive corticosteroids. Presence of Child C status and high serum creatinine value (≥ 1.35 mg/dL) accurately predicted mortality. Newer treatment options need to be explored for these patients.

[Acute-on-chronic liver failure (ACLF) is a separate clinical entity]. / Akut-på-kronisk leversvikt är en egen klinisk entitet-Leder till svikt i ett eller flera organ-understödjande IVA-vård kan vara livräddande.

Acute-on-chronic liver failure (ACLF) is a condition that may develop in up to one third of patients with chronic liver disease who exhibit clinical signs of acute decompensation, i.e. ascites, gastrointestinal bleeding, hepatic encephalopathy or bacterial infection. ACLF implies the combination of acute hepatic decompensation with organ failure in kidney, brain, liver, lungs, circulation and/or coagulation. The prognosis worsens with the number of failing organs, renal involvement, advanced age and elevated leukocyte blood count. ACLF is caused by a systemic inflammation. Cultures from blood, urine and ascites should be drawn, and rapid antibiotic treatment is essential to prevent ACLF development. Renal function must be monitored and renal failure treated promptly. Acute alcoholic hepatitis may be considered a specific case of ACLF, which may be treated with corticosteroids in cases having high score in prognostic indices (GAHS, MELD or ABIC), and after bacterial infections have been ruled out or treated.

Nationwide longitudinal analysis of acute liver failure in taiwan.

Acute liver failure (ALF) is uncommon but fatal. Current management is based mostly on clinical experience. We aimed to investigate the incidence, etiology, outcomes, and prognostic factors of ALF in Taiwan. Patients with the admission diagnosis of ALF between January 2005 and September 2007 were identified from the Longitudinal Health Insurance Database of Taiwan. ALF was further confirmed by disease severity based on laboratory orders, prescriptions, and duration of hospital stay, and acute onset without prior liver disease. Prognostic factors were identified using Cox regression analysis. During the study period, 218 eligible cases were identified from 28,078 potential eligible ALF patients. The incidence was 80.2 per million person-years in average and increased with age. The mean age was 57.9 ±â€Š17.1 years and median survival was 171 days. The most common etiologies were viral (45.4%, mainly hepatitis B virus) and followed by alcohol/toxin (33.0%). Independent prognostic factors included alcohol consumption (hazard ratio, HR, 1.67 [1.01-2.77]), malignancy (HR 2.90 [1.92-4.37]), frequency of checkups per week for total bilirubin (HR 1.57 [1.40-1.76]), sepsis (HR 1.85 [1.20-2.85]), and the use of hemodialysis/hemofiltration (HR 2.12 [1.15-3.9]) and proton pump inhibitor (HR 0.94 [0.90-0.98]). Among the 130 patients who survived ≥90 days, 66 (50.8%) were complicated by liver cirrhosis. Eight (3.7%) were referred for liver transplantation evaluation, but only 1 received transplantation and survived. ALF in Taiwan is mainly due to viral infection. Patients with malignancy and alcohol exposure have worst prognosis. The use of proton pump inhibitor is associated with improved survival. Half of the ALF survivors have liver cirrhosis.

[Hepatology scores]. / Hepatologische Scores.

We are performing a complex medicine in an environment of limited resources. Therefore we need to accurately diagnose, predict and treat. Many scores have been developed with these goals in Hepatology. We choose to limit our attention to those widely used and established which are really decisive in daily clinical management: the Child-Pugh-Turcotte-Score (CTP); the MELD-Score, the simplified criteria for the diagnosis of autoimmune hepatitis, the Mayo-Score for primary biliary cirrhosis and the Lille-Score for alcoholic hepatitis. All scores use clinical features as well as laboratory findings to make these statements. It is likely that these scores will remain in clinical practice for many more years even if new scores based on molecular signatures may be introduced in a near future.

Utility of the Mayo End-Stage Liver Disease (MELD) score in assessing prognosis of patients with alcoholic hepatitis.

BACKGROUND: Alcoholic hepatitis is characterized by acute, or acute-on-chronic hepatic failure and associated with a high mortality. Specific therapies should be considered for those at high risk of mortality. The Mayo End-Stage Liver Disease (MELD) score is a marker of disease severity and mortality in persons with chronic alcoholic liver disease. Our aims were to assess the utility of the MELD score as a predictor of short-term mortality in persons with alcoholic hepatitis. METHODS: We assessed the utility of the MELD score and compared it with the Discriminant Function (DF) as a predictor of mortality in 34 patients hospitalized with alcoholic hepatitis. RESULTS: The area under the curve of a receiver operating characteristic curve for the MELD score was 0.82 (confidence intervals 0.65-0.98), and for the DF was 0.86 (confidence intervals 0.70-1.00). However, the sensitivity and specificity in predicting 30-day mortality for a MELD score of greater than 11 was 86% and 81%, but for a DF greater than 32 was 86% and 48% respectively. The presence of ascites and bilirubin greater than 8 mg/dL were also highly predictive of mortality with a sensitivity of 71% and a specificity of 96%. CONCLUSIONS: Alcoholic hepatitis remains associated with a high mortality in hospitalized patients. The MELD score performs as well as the DF in predicting mortality at 30 days. A MELD score of greater than 11, or the presence of both ascites and an elevated bilirubin greater than 8 mg/dL should prompt consideration of specific therapeutic interventions to reduce mortality.

[Does alcoholic chronic hepatitis exist?]. / Sushchestvuet li alkogol'nyi khronicheskii gepatit?

Alcoholic chronic hepatitis (ACH) can be considered as an independent nosological entity. This conclusion can be made basing on the literature devoted to the mechanisms of ethanol effects on the liver and clinicomorphological features of hepatic ethanol damage. ACH should be included into the new 1994 International classification of chronic hepatitis. Special attention is paid to a higher incidence of combined liver damage induced by alcohol and hepatotropic viruses, especially by hepatitis C virus. Combined virus-alcoholic liver damage will become, in the author's opinion, one of the most important hepatology problems in the coming millenium.

Usefulness of technetium-99m-galactosyl human serum albumin liver scintigraphy for assessment of severity of alcoholic hepatitis.

We performed a liver scintigraphy using technetium-99m diethylene-triaminepentaacetic acid-galactosyl human serum albumin (99mTc-GSA), which images the functional liver mass through its binding to the specific receptor asialoglycoprotein receptor in patients with severe alcoholic hepatitis. Receptor index (LHL 15) was significantly lower in patients with alcoholic hepatitis, compared with controls with normal liver. Difference in the isotope uptake patterns between liver and heart varied according to the severity of liver disease, and made it possible to categorize 5 grades. Grading score could discriminate between the eventual outcome of the patients. Furthermore, single photon emission computed tomography showed the variable uptake patterns in the hepatic lobule, wherein there were no evident findings in macroscopic view at autopsy. The results of this study show the usefulness of 99mTc-GSA scintigraphy in the evaluation and prognosis of alcoholic hepatitis.

Elevation of chemotactic factor inactivator in alcoholic liver disease.

Defective regulation of neutrophil chemotaxis occurs in patients with alcoholic liver disease. One potent mediator of neutrophil chemotaxis is the complement-derived neutrophil chemoattractant, C5a, which can be inhibited by a serum protein, chemotactic factor inactivator. We hypothesized that chemotactic factor inactivator elevation might, in part, explain the defective neutrophil chemotaxis seen in patients with alcoholic hepatitis. To test this hypothesis, sera were collected from 22 patients with alcoholic hepatitis and 9 normal controls, and evaluated for the antigenic presence of chemotactic factor inactivator using an ELISA test. Chemotactic factor inactivator levels were found to be markedly elevated in patients with alcoholic hepatitis (162 +/- 24 micrograms per ml) compared to normals (60 +/- 3 micrograms per ml, p less than 0.01). Subdividing the hepatitis patients revealed that the elevation of chemotactic factor inactivator was found to be greatest in those patients with mild alcoholic hepatitis (prothrombin time within normal limits and bilirubin less than or equal to 5 mg per dl, 256 +/- 44 micrograms per ml, p less than 0.001), while the group with the severest hepatic dysfunction (prolonged prothrombin time and bilirubin greater than 5 mg per dl) did not differ significantly from controls (71 +/- 11 micrograms/ml, p less than 0.2). Importantly, the inhibition of C5a-induced chemotactic activity by partially purified chemotactic factor inactivator correlated with antigenic amounts of chemotactic factor inactivator in serum (r = 0.63, p less than 0.05). The C5a inhibitory activity in sera obtained from patients with alcoholic hepatitis coprecipitated with chemotactic factor inactivator when serum was precipitated by ammonium sulfate precipitation (45 to 64% saturation).(ABSTRACT TRUNCATED AT 250 WORDS)

[Hepatitis and cirrhosis of the liver (classification, morphology and morphological differential diagnosis]. / Gepatiti, tsirroz pecheni (klassifikatsiia, morfologiia, morfologicheskaia differentsial'naia diagnostika).

The current classification of hepatitis and hepatocirrhosis is evaluated on the basis of the literature analysis and the study of the author's own material. Morphological criteria for differential diagnosis of liver diseases of viral and alcohol etiology are proposed. A clinical pathologist examining a liver biopsy may confirm or establish the etiology of the disease, determine the degree of activity and compensation of the process. An analysis of these criteria helps a clinician to choose the method of treatment and to determine the prognosis of the disease.