Perfil clínico y resultados de la pancreatitis aguda en la Unidad de Cuidados Intensivos e Intermedios de un hospital general / Clinical profile and results of acute pancreatitis in the Intensive and Intermediate Care Unit of a general hospital

RESUMEN La pancreatitis aguda (PA) es un proceso inflamatorio agudo del páncreas que, de acuerdo con la clasificación de Atlanta del 2012, puede ser leve, moderada o grave. Objetivo: Describir las características epidemiológicas, clínicas, terapéuticas y los resultados de pacientes con PA ingresados a la unidad de cuidados intensivos e intermedios de un hospital general y compararlos con los descritos en la literatura nacional e internacional. Materiales y métodos: Estudio observacional de pacientes con PA atendidos en un periodo de 3 años. Resultados: Se incluyeron 59 casos; predominó el sexo femenino (54,2%), la edad media fue de 59,3 años, la etiología más frecuente fue biliar (84,7%). Los puntajes de severidad promedio al ingreso fueron APACHE II de 12,4 puntos, SOFA de 4,9 puntos y Marshall modificado de 2,8 puntos; la falla orgánica más frecuente fue la respiratoria (47,5%). La estancia media en cuidados fue 13,9 días y en el hospital fue de 23,3 días. Ningún paciente con PA leve o moderada falleció durante su estancia hospitalaria, 6 pacientes con PA grave fallecieron durante su estancia hospitalaria (20% de los casos de PA grave). Conclusión: Los casos de nuestro hospital tuvieron un perfil clínico y terapéutico semejante al descrito en la literatura mundial y latinoamericano. Se evidenció una estancia hospitalaria mayor a la descrita en trabajos recientes, pero nuestra mortalidad fue menor.

ABSTRACT Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that, according to the 2012 Atlanta classification, can be mild, moderate or severe. Objective: Describe the epidemiological, clinical, therapeutic and outcomes of patients with AP admitted to the intensive care and intermediate care unit of a general hospital and compare them with those described in the national and international literature. Materials and methods: Observational study of patients with AP treated over a period of 3 years. Results: 59 cases were included; the female sex prevailed (54.2%), the average age was 59.3 years, the most frequent etiology was biliary (84.7%). Average entry severity scores were APACHE II of 12.4 points, SOFA of 4.9 points and Marshall modified of 2.8 points; The most frequent organ failure was respiratory (47.5%). The average stay in care was 13.9 days and in the hospital it was 23.3 days. No patients with mild or moderate AP died during their hospital stay, 6 patients with severe AP died during their hospital stay (20% of cases of severe AP). Conclusion: The cases of our hospital had a clinical and therapeutic profile similar to that described in the world and Latin American literature. A hospital staying was greater than that described in recent works, but our mortality was lower.

Analysis of influencing factors of severity in acute pancreatitis using big data mining

SUMMARY OBJECTIVES To evaluate the epidemiological characteristics of acute pancreatitis (AP) and explore potential relationships between these factors and severity. METHODOLOGY Data-sets of 5,659 patients with AP from health statistics and the Information Center of Jiangsu province, between 2014 and 2016, were analyzed. A self-organizing map (SOM) neural network was used for data clustering. RESULTS Biliary acute pancreatitis (BAP) (86.7%) was the most frequent etiological factor. A total of 804 (14.2%) patients had severe acute pancreatitis (SAP). The mean age of patients was 53.7 + 17.3 (range 12~94y). Most of the AP patients were married (75.4%); 6% of mild /moderately severe AP (MAP/MASP) patients were unmarried, which was less than SAP patients (P=0.016). AP patients with blood type AB in the general population (8.8%) was significantly lower than that of AP cases (13.9%) (P=0.019) and SAP cases(18.7%) (P=0.007). The number of AP patients in southern Jiangsu was much higher than that in northern Jiangsu province, especially in Nanjing (1229, 21.7%). The proportion of acute alcoholic pancreatitis (AAP) in the north of Jiangsu (Xuzhou 18.4%) was much higher than that in southern Jiangsu (Suzhou 2.6%). The whole sample was divided into five classes by SOM neural network. If BAP patients were male, old, divorced, and blood type AB or B, they were more likely to develop SAP. Middle-age, unmarried or divorced male patients with blood type B/AB who suffered from HAP or AAP were also more likely to develop SAP. CONCLUSIONS The number of unmarried patients with MAP/MASP was smaller than that of SAP. Blood types AB and B were more frequent in AP, especially in SAP. The differences between southern Jiangsu and northern Jiangsu, in number of AP patients and the proportion of AAP, were significant. In class I and class IV, the ratio of SAP was much higher than in other classes and the whole sample.

Páncreas divisum y pancreatitis: su importancia en la práctica cotidiana / Pancreas divisum and pancreatitis: its importance in everyday practice

Pancreas divisum (PD) is the most common congenital anatomical variant of the pancreas. Its etiological implication in recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) has been recurrently questioned. Normal anatomy and variants: 80-90% of the population has normal anatomy, with excretion of exocrine pancreatic secretion to the duodenum by the major papilla. Three anatomical variants of PD have been described: classic PD with visible ventral duct, but total absence of fusion; PD with absence of ventral duct; and incomplete PD, with a rudimentary connection between the ventral and dorsal ducts. Clinical implication: This anatomical variant is symptomatic in less than 5% of the carriers, being associated to higher prevalence in patients with RAP However, the relationship between PD and RAP is considered probable, only in cases of association with mutation of the CFTR gene. Obstructive CP can develop in the segment drained by the dorsal duct. Diagnosis: Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive diagnostic method. Other non-invasive diagnostic methods are endosonography and computed tomography (CT), the latter with lower performance. Treatment: The current trend in acute pancreatitis (AP) where PD is assumed as an etiological factor, is endoscopic resolution, with papillotomy with or without a pancreatic stent.

El páncreas divisum (PD) es la variante anatómica congénita más frecuente del páncreas. Su implicancia etiológica en pancreatitis aguda recurrente (PAR) y pancreatitis crónica (PC) ha sido frecuentemente cuestionada. Anatomía normal y variantes: 80-90% de la población presenta anatomía normal, con salida de secreción pancreática exocrina al duodeno por la papila mayor. Se han descrito 3 variantes anatómicas: PD clásico con conducto ventral visible, pero ausencia total de fusión; PD con ausencia de conducto ventral; y PD incompleto, con conexión rudimentaria entre los conductos ventral y dorsal. Implicancia clínica: Esta variante anatómica da síntomas en menos de 5% de los portadores, asociándose a mayor prevalencia en pacientes con PAR. Sin embargo, se considera probable la relación entre PD y PAR, solo en casos de asociación con mutación del gen CFTR. Pancreatitis crónica (PC) obstructiva se puede desarrollar en el segmento drenado por el conducto dorsal. Diagnóstico: La colangiopancreatografía por resonancia magnética (CPRM) es el método diagnóstico más sensible. Otros métodos diagnósticos no invasivos son la endosonografía y tomografía computada (TC), este último de menor rendimiento. Tratamiento: La tendencia actual en PA donde se asume PD como factor etiológico, es la resolución endoscópica, con papilotomía con o sin stent.

Acute pancreatitis associated with boceprevir: a case report

Approximately 170 million people are infected with hepatitis C, and the sustained virological response rate to treatment with pegylated interferon and ribavirin is 30-50%. In an attempt to improve the chances of cure, boceprevir is being added to therapy, but it is associated with an increased incidence of adverse events. We herein report a case of acute pancreatitis developed during treatment with pegylated interferon, ribavirin and boceprevir. Boceprevir was the most likely cause of drug-associated pancreatitis after the most common causes were ruled out, since this adverse event had not occurred when the patient had previously been exposed to pegylated interferon and ribavirin and there was no recurrence of the episode of pancreatitis when these two drugs were reintroduced. Acute pancreatitis is a rare adverse event associated with boceprevir therapy, but a potentially fatal event. Sequential determination of pancreatic enzymes should be considered during hepatitis C treatment with boceprevir.

Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature / Groove pancreatitis vs groove pancreatic adenocarcinoma. Report of two cases and review of the literature.

Groove pancreatitis (GP) is a rare form of segmental chronic pancreatitis affecting the groove area (anatomic space between the head of the pancreas, the duodenum and the common bile duct). Its clinical and radiological presentation may be similar to groove pancreatic adenocarcinoma (GPA). Nevertheless, treatment and prognosis are totally different. We report two cases of both GP and GPA and review the relevant aspects that may help to clarify the differential diagnosis between these two rare entities. The first patient is a 57-year-old man with a history of chronic alcohol consumption who presented with persistent abdominal pain. The CT-scan findings suggested GP. Due to the persistence of symptoms despite medical treatment, a pancreaticoduodenectomy was performed. Pathologic evaluation confirmed the diagnosis of GP. The second patient is a 72-year-old male who presented with cholestasis and weight loss. The tumor marker CA 19-9 was increased The CT-scan findings were consistent with duodenal dystrophy. In order to rule out malignancy a pancreaticoduodenectomy was performed. Pathologic evaluation revealed a pancreatic head adenocarcinoma (T3-N1-M0). GP is a rare entity that should be suspected in patients with a history of heavy alcohol consumption who complain of chronic abdominal pain and weight loss. Patients without a clear diagnosis even after a through imaging work-up, or those in whom symptoms are persistent in spite of medical therapy, should undergo surgical exploration.

Pancreatitis autoinmune tipo 1: revisión a partir de un caso clínico / Autoimmune pancreatitis type 1: case report and review of the literature

Introduction: Autoimmune pancreatitis (AIP) is one of the etiologies of chronic pancreatitis, which is classified in two subtypes: type 1 that is part of a fibroinflammatory systemic disease associated with IgG4; and type 2, confined to pancreatic tissue without IgG4 association. Both forms typically present as abdominal pain associated with obstructive jaundice. Radiologically it is characterized by diffuse or focal enlargement of the pancreas, becoming essential to differentiate from pancreatic cancer. Case report: We report the case of a 74 year-old patient who presented obstructive jaundice and abdominal pain, images with diffusely increased pancreatic volume and elevated serum IgG4. She was treated with prednisone with an excellent clinical and laboratory response. Conclusion: AIP is a disease with high clinical suspicion, well-established diagnostic criteria and standardized treatment, showing a high rate of response to treatment of first and second line. AIP pancreatitis diagnosis should be considered facing over patients with acute pancreatitis, chronic pancreatitis or pancreatic cancer.

Introducción: La pancreatitis autoinmune (PAI) es una causa de pancreatitis crónica que se clasifica en dos subtipos: la tipo 1, que es parte de una enfermedad fibroinflamatoria sistémica asociada a IgG4; y la tipo 2, limitada al tejido pancreático y sin asociación a IgG4. Ambas se presentan típicamente como un cuadro de dolor abdominal asociado a ictericia obstructiva. Imagenológicamente se caracteriza por aumento de volumen difuso o focal del páncreas, haciéndose indispensable hacer el diagnóstico diferencial con el cáncer de páncreas. Caso clínico: Presentamos el caso de una paciente de 74 años con ictericia obstructiva y dolor abdominal, imágenes con aumento difuso de volumen pancreático e IgG4 plasmática elevada. Se trata con prednisona con excelente respuesta clínica y de laboratorio. Conclusión: La PAI es un cuadro de alta sospecha clínica, con criterios diagnósticos bien establecidos y tratamiento estandarizado, presentando una alta tasa de respuesta a tratamiento de primera y segunda línea. El diagnóstico de PAI debe ser considerado al enfrentar un paciente con pancreatitis aguda, crónica o cáncer de páncreas.

Estudio y manejo de la pancreatitisaguda recurrente / Study and management of recurrent acute pancreatitis

Acute pancreatitis is caused by biliary lithiasis or alcohol consumption in 70-90 percent of the cases; however, depending on the depth of the etiological study, 5 to 30 percent of the cases do not have an apparent cause. An undetected condition that is potentially amendable may lead to recurrent episodes of acute pancreatitis. Among the proposed strategies for the management of idiopathic acute pancreatitis patients (first or recurrent episode) it is suggested –in addition to repeated transabdominal ultrasound and the clinical laboratory tests– the performance of other studies such as: microscopic examination of bilis to demonstrate biliary sludge or microlithiasis; endoscopic ultrasound, that in addition to its high sensitivity for detecting bilairy lithiasis, it also helps to detect solid, cystic or periampullary pancreatic lesions, early changes of chronic pancreatitis and other biliopancreatic anatomical conditions; same as nuclear magnetic resonance (NMR). Diagnostic endoscopic retrograde cholangiopancreatography (ERCP) has left its place to the mentioned imaging studies, but keeping its diagnostic role in the manometric study of the sphincter of Oddi when suspecting a disorder. Presentation of patients with chronic pancreatitis as well as recurrent pancreatitis episodes expands the scope of search. Prophylactic cholecystectomy without futher investigation is a plausible alternative due to hte high frequency of lithiasic disease, mainly considering the low availability and high cost of the proposed studies. In cholecystectomized patients, prophylactic ERCP without futher investigation showing a potentially treatable disease using this or other methods is discouraged, due to the high frequency of acute pancreatitis post-ERCP, if the underlying disease is an Oddi sphincter dysfunction. In this case it is suggested that the procedure must be performed in a health center with vast experience in this technique.

La pancreatitis aguda es causada en un 70-90 por ciento por litiasis biliar o consumo excesivo de alcohol, pero, dependiendo de la profundidad del estudio etiológico realizado, 5 a 30 por ciento de los casos no tienen causa aparente. La falta de detección de una condición potencialmente corregible puede llevar a episodios recurrentes de pancreatitis aguda. Entre las diferentes estrategias propuestas para el manejo de pacientes con pancreatitis aguda idiopática (sea primer episodio o episodio recurrente), se sugiere, además de repetir la ecografía transabdominal y el laboratorio bioquímico habitual, realizar estudios como: el análisis microscópico de bilis para demostrar barro biliar o microlitiasis; ultrasonografía endoscópica, que además de una alta sensibilidad para detectar litiasis biliar permite también la detección de lesiones sólidas o quísticas pancreáticas o periampulares, cambios precoces de pancreatitis crónica y otras alteraciones anatómicas biliopancreáticas; al igual que la resonancia nuclear magnética (RNM). La colangiopancreatografía retrógrada endoscópica (CPRE) diagnóstica ha cedido su lugar a los estudios de imágenes antes mencionados, manteniendo su papel diagnóstico en el estudio manométrico del esfínter de Oddi ante la sospecha de disfunción. La presentación de pacientes con pancreatitis crónica como crisis de pancreatitis recurrente amplía el espectro de búsqueda. La colecistectomía profiláctica sin mayor estudio es una alternativa planteable dada la alta frecuencia de patología litiásica, sobre todo considerando la baja disponibilidad y alto costo de los estudios propuestos. En pacientes colecistectomizados, la CPRE profiláctica sin nuevos estudios que demuestren una patología eventualmente tratable por este u otros métodos, se desaconseja por la alta frecuencia de pancreatitis aguda post CPRE si la patología subyacente es una disfunción del esfínter de Oddi. Se sugiere en este caso su realización en centros con amplia experiencia...

BISAP como predictor de gravedad en pacientes con pancreatitis aguda: experiencia en el Servicio de Emergencia del Hospital Daniel A. Carrión del Perú / BISAP as severity predictor in patients with acute pancreatitis: experience in the emergency service at Daniel A. Carrión Hospital in Peru

Acute pancreatitis is an inflammatory disease resulting from the autodigestion of the pancreas by the pancreatic enzymes secreted by this organ. Many parameters and scores have been developed with the purpose of accurate and early prediction of the severity of this disease in order to reduce its mortality rates. In 2008, the BISAP score was validated. This score has five variables for predicting mortality, which can be easily performed when the patient is admitted to the emergency service. Objective: To determine the sensibility and specificity of BISAP's score to predict severity in the emergency Department of the Daniel A. Carrion Hospital. Methods: Patients with diagnosis of acute pancreatitis, between June 2009 and May, 2010 were included. Severity scores were assessed in order to predict the progress. Results: 162 patients were evaluated, 123 female (75.9 percent), and 39 male (24.1 percent). The average age of presentation was of 47 years. 14.8 percent (24 patients) were diagnosed with severe pancreatitis. The ROC curve was 0.801; 0.795 and 0.857 for the RANSON, APACHE II and BISAP, respectively. In was not possible to analyze the mortality prediction, because the number of deaths in this study was only 2. Conclusions: BISAP's score is a simpler method for predicting the severity of the patients with acute pancreatitis in the first 24 hours in the emergency department with an efficacy comparable to traditional scores. In this study it was not possible to assess BISAP's score as predictor of mortality for the patients with acute pancreatitis.

La pancreatitis aguda es una enfermedad inflamatoria que resulta de la autodigestión del páncreas por las enzimas que secreta el propio órgano. Muchos parámetros y scores han sido creados con la intensión de lograr predecir adecuada y precozmente la gravedad de la pancreatitis para así poder disminuir su mortalidad. En 2008 se validó el score BISAP, el cual consta de cinco variables para la predicción de mortalidad las cuales pueden realizarse fácilmente al momento del ingreso del paciente a la emergencia. Objetivo: Determinar si el BISAP es útil como factor pronóstico para predecir la gravedad de la pancreatitis aguda. Métodos: Estudio donde fueron incluidos pacientes con diagnóstico de pancreatitis aguda entre junio de 2009 y mayo de 2010 y se evaluó scores de gravedad para predecir la evolución de la enfermedad. Resultados: 162 pacientes fueron evaluados con el score BISAP, 123 mujeres (75,9 por ciento) y 39 varones (24,1 por ciento), edad promedio 47 años; 14,8 por ciento (24 pacientes) fueron diagnosticados con pancreatitis grave. El área bajo la curva para el score de RANSON, APACHE II y BISAP fue 0,80; 0,795 y 0,857, respectivamente. No fue posible analizar la predicción de mortalidad porque sólo se presentaron 2 defunciones. Conclusiones: BISAP es un método más sencillo y rápido que puede ser utilizado como predictor de gravedad en los servicios de emergencia y con eficacia comparable a los scores tradicionales.

Pancreatite na gestação / Pancreatitis in pregnancy

Pancreatite caracteriza-se por processo inflamatório do pâncreas, apresentando ruptura da membrana celular e proteólise tecidual, seguida da ativação de células da resposta imunológica. É uma afecção de amplo espectro clínico e apresenta variadas etiologias. Durante a gestação, merece devida relevância em função da alta morbi-mortalidade que a acompanha. A litíase das vias biliares é o fator etiológico predominante na patogênese da pancreatite aguda durante a gravidez, sendo que as gestantes podem desenvolver pancreatite aguda associada à hiperlipidemia. O diagnóstico clínico é raro e deve ser feito o diagnóstico diferencial com outras patologias. A avaliação lavoratorial é normalmente caracterizada por grandes elevações da amilase sérica, isoamilase pancreática e lipase. O tratamento do quadro de pancreatite aguda durante a gravidez objetiva a redução de estímulos à secreção das enzimas pancreáticas. Diagnóstico precoce e identificação da etiologia aliada à escolha terapêutica adequada asseguram bom prognóstico materno e fetal. A interrupção da gravidez parece não interferir no prognóstico da doença. Objetivou-se, com a presente revisão, abordar aspectos relevantes da pancreatite em gestantes, tais como fisiopatologia, diagnóstico, terapêutica e prognóstico.

Pancreatitis is characterized by inflammation of pancreas, showing disruption of the cell membrane and tissue proteolysis, followed by the activation of cells of immune response. It is a broad clinical spectrum disease and presents varied etiologies. During pregnancy, it deserves importance due to the high morbidity and mortality that accompany it. The lithiasis of the bile is the main etiologic factor in the pathogenesis of acute pancreatitis during pregnancy, and the pregnant women may develop acute pancreatitis associated with hyperlipidemia. Clinical diagnosis is rare and differential diagnosis should be made with other pathologies. The laboratory evaluation is usually characterized by high elevations of serum amylase, pancreatic isoamilase and lipase. The treatment for acute pancreatitis during pregnancy aiming the reduction of stimuli to the secretion of pancreatic enzymes. Early diagnosis and identification of etiology allied to appropriate therapy choice assurance good maternal and fetal prognosis. The interruption of pregnancy does not appear to influence the prognosis of the disease. The objective of this review was to approach relevant aspects of pancreatitis during pregnancy, such as pathophysiology, diagnosis, therapeutics and prognosis.

Hemoconcentración, apache II y ranson como predictores tempranos de severidad en pacientes con diagnóstico de pancreatitis aguda en un Hospital de Lima - Perú / Hemoconcentration, apache II and ranson as early predictors of severity in patients with acute pancreatitis in a hospital in Lima - Peru

OBJETIVO: Comparar hemoconcentración y sistemas de puntuación APACHE II y Ranson como predictores tempranos de severidad determinada por criterios de Atlanta en pacientes con diagnóstico de Pancreatitis Aguda en el Hospital Nacional Cayetano Heredia. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo entre diciembre del 2009 a noviembre del 2010 con una ficha de recolección de datos para obtener la información relevante. Se clasificó los cuadros de pancreatitis aguda en leve y severa en base a los criterios de falla orgánica y/o complicaciones locales según el Simposio de Atlanta. Para la comparación del valor de hematocrito se realizó la prueba t de Student para evaluar una diferencia significativa y se elaboró la curva ROC para las áreas bajo la curva. RESULTADOS: Ingresaron al estudio 151 pacientes, 103 mujeres (68.2%), edad promedio de 45.5 ± 19.17 años, 112 pancreatitis leves (74.2%) y 39 severas (25.8%). El hematocrito promedio en los casos leves fue de 38.40 ± 4.77%, y 39.78 ± 7.35% en los severos con p igual a 0.182. Se encontró un área bajo la curva de 0.89 y 0.68 para score APACHE II y Ranson, respectivamente. CONCLUSIÓN: Hemoconcentración y Ranson no son buenos predictores de severidad comparados con el APACHE II en Pancreatitis Aguda.

OBJECTIVE: Compare hemoconcetration, APACHE II and Ranson scores as early predictors of severity defined by Atlanta criteria in patients with acute pancreatitis at Hospital Nacional Cayetano Heredia. MATERIALS AND METHODS: Retrospective descriptive study between December 2009 to November 2010 done using a data collection sheet to gather study relevant information. We classified acute pancreatitis into mild or severe according to Atlanta symposium criteria for organ failure and/or local complications. Comparison of hematocrit values was made using a t Student test to detect a significant difference and the area below the ROC curve was analyzed. RESULTS: Counting with 151 patients, 103 women (68.2%), with mean age of 45.5 ± 19.17 years, 112 mild pancreatitis (74.2%) and 39 severe (25.8%). Mean hematocrit in mild cases was 38.40 ± 4.77% and 39.78 ± 7.35% in severe group with p equal to 0.182. Area below the ROC curve of 0.89 y 0.68 for APACHE II and Ranson scores respectively. CONCLUSION: Hemoconcentration and Ranson proved not to be as useful as APACHE II score in predicting severity in acute pancreatitis.

Determinación de proteína C reactiva como predictor de severidaden pancreatitis aguda / Predictive value of PCR for severity, complications and hospital mortality of acute pancreatitis

INTRODUCCION: La proteína C reactiva (PCR) es un examen simple y de bajo costo que según la literatura tiene buena asociación para la evaluación pronóstica en Pancreatitis Aguda (PA). OBJETIVO: Determinar valor pronóstico de PCR para severidad, presencia de complicaciones y mortalidad intrahospitalaria de PA. MATERIAL Y METODO: Estudio de cohorte retrospectiva de pacientes adultos ingresados al Hospital Dr. Gustavo Fricke, Viña del Mar durante el año 2007. Se identificaron características generales, etiología, score de Balthazar, PCR, complicaciones y mortalidad. Se utilizó test de Mann Whitney para comparación de medianas y curvas ROC. RESULTADOS: Se incluyeron 59 pacientes, siendo el 54,23 por ciento hombres. La mediana de edad fue 51 años. La etiología biliar se observó en 57,62 por ciento. La mediana de hospitalización fueron 12 días. El 40,67 por ciento presentó complicaciones, siendo más frecuente la necrosis pancreática (20,33 por ciento). El nivel de PCR mostró diferencias significativas entre pacientes con y sin gravedad imagenológica (33,5mg/dL vs 15,9mg/dL, p=0,0009), complicaciones intrahospitalarias (40mg/dL vs 15,9mg/dL, p<0,0001) y mortalidad intrahospitalaria (66mg/dL vs 22mg/dL, p=0,0061). El área bajo la curva ROC fue de 0,75; 0,84 y 0,91 respectivamente, todos estadísticamente significativos. La sensibilidad, especificidad, likelihood ratio (LR) positivo, LR negativo para gravedad imagenológica con un punto de corte de 13,14mg/dL fue 88 por ciento, 54 por ciento, 1,83 y 0,28 respectivamente. Para predecir mortalidad con un valor de 32,76mg/dL, estos fueron 100 por ciento, 71 por ciento, 3,43 y 0 respectivamente. DISCUSION. Un valor de PCR de 40mg/dL es buen marcador pronóstico de complicaciones intrahospitalarias. Niveles aumentados tienen alta sensibilidad para predecir gravedad imagenológica y mortalidad intrahospitalaria.

INTRODUCTION: C-reactive protein (CRP) is a simple and low price test with good association in acute pancreatitis (AP) prognosis evaluation. OBJECTIVE: To determine predictive value of PCR for severity, complications and hospital mortality of AP. MATERIAL AND METHODS: Retrospective cohort study of adult patients admitted to Dr. Gustavo Fricke Hospital, Viña del Mar in 2007. General characteristics, etiology, Balthazar score, CRP, and mortality rates were identified. Mann Whitney U test for comparison of medians and ROC curves were used for the analysis. RESULTS: 59 patients were included, 54.23 percent were males. The median age was 51 years. The biliary etiology was observed in 57.62 percent. The average hospitalization period was 12days. Complications were observed in 40.67 percent, being pancreatic necrosis the most frequent one (20.33 percent). The CRP level showed significant differences between patients with and without imaging severity (33.5 mg/dL vs 15.9 mg/dL, p=0.0009), hospital complications (40mg/dL vs 15.9mg/dL, p<0,0001) and hospital mortality (66mg/dL vs 22mg/dL, p=0.0061). The area under the ROC curve was 0.75, 0.84 and 0.91 respectively, all statistically significant. The sensitivity, specificity, positive likelihood ratio (LR), negative LR gravity imaging with a cut off of 13.14 mg/dL was 88 percent, 54 percent, 1.83 and 0.28 respectively. To predict mortality with a value of 32.76 mg/dL, they were 100 percent, 71 percent, 3.43 and 0 respectively. DISCUSSION: The 40mg/dL CRP value is a good prognostic marker of hospital complications. Increased level has high sensitivity to predict imaging severity and hospital mortality.

Curso de atualização em emergências médicas: aula 15: pancreatite aguda: diagnóstico e terapêutica / Course of updating in medical emergencies: class 15: acute pancreatitis: diagnosis and therapeutics

A evolução clínica de um episódio de pancreatite aguda varia de um quadro autolimitado, benigno, restrito ao abdome, a uma doença sistêmica, grave, de evolução imprevisível e por vezes fatal. Embora a maioria se apresente de forma benigna (80 por cento a 90 por cento), também denominada pancreatite aguda leve, cerca de 10 por cento a 20 por cento mostram-se potencialmente graves e têm como marco principal a necrose pancreática e(ou) peripancreática. Apesar de inúmeras etiologias, 80 por cento a 90 por cento são decorrentes de colelitíase, em especial microlitíase, e alcoolismo. A mortalidade é desprezível na forma leve da doença, mas preocupante em sua forma grave, com índices variando de 20 por cento a 40 por cento. A falência múltipla de órgãos e a infecção sistêmica (sepse) são os grandes responsáveis por esta alta letalidade na PA necrosante. O melhor conhecimento das formas evolutivas, a aquisição de métodos de imagem diagnósticos e terapêuticos, o setor especializado de terapia intensiva e a maior experiência de equipes interdisciplinares têm promovido uma queda significativa na morbiletalidade.

The clinical evolution of an episode of acute pancreatitis vary from self-limited condition, benign, restrict to the abdomen to a systematic disease, severe, of an inexact and some time fatal evolution. Although most of them appear in a benign form (80 percent - 90 percent), about 10 percent - 20 percent of the also called mild acute pancreatitis is potentially severe and has its beginning as a pancreatic and(or) peripancreatic necrosis. Despite many etiologies, 80 percent - 90 percent are due to cholelithiasis, especially microlithiasis and alcoholism. Mortality is insignificant in the mild form of the disease, but worrisome when it comes to severe acute pancreatitis, when the indexes vary in 20 percent -40 percent. Multiple organ failure and systemic infection (sepsis) are the most responsible for the high mortality rate of the necrotizing PA. Knowing better the evolutionary forms aquisition of diagnostic and therapeutic image methods, specializes department in critical care and a more experienced and interdisciplinary staff have promoted a significant decrease in morbilethality.

Relação lipase/amilase nas pancreatites agudas de causa biliar e nas pancreatites agudas/crônicas agudizadas de causa alcoólica / Lipase/amylase ratio in biliary acute pancreatitis and alcoholic acute/acutized chronic pancreatitis

RACIONAL: Pancreatites agudas de causas alcoólica ou biliar podem necessitar de abordagens terapêuticas diferentes. OBJETIVO: Verificar a validade da relação lipase/amilase em diferenciar as causas alcoólica ou biliar na pancreatite aguda/pancreatite crônica agudizada. MÉTODOS: Foram avaliados nove pacientes com pancreatite aguda/pancreatite crônica agudizada alcoólica, todos homens, com idade média (desvio padrão) de 39,8 ± 7,0 anos (grupo I) e 29 com pancreatite aguda biliar, sendo 8 homens e 21 mulheres, com idade média de 43,6 ± 19,9 anos (grupo II). As amilasemias e lipasemias foram determinadas em pacientes com sintomatologia há, no máximo, 48 horas. A relação lipase/amilase foi calculada utilizando-se valores de amilasemia e lipasemia expressas como múltiplos de seus respectivos valores superiores de referência. RESULTADOS: As médias das lipasemias (4.814 ± 3.670 U/L) e amilasemias (1.282 ± 777 U/L) no grupo I foram semelhantes às do grupo II (2.697 ± 2.391 e 1.878 ± 1.319 U/L, respectivamente), mas a média das relações lipase/amilase foi significantemente maior no grupo I (4,4 ± 3,6) do que no grupo II (2,2 ± 2,2). Relação lipase/amilase >3 foi significantemente mais freqüente no grupo I (66,7 por cento) do que no grupo II (24,1 por cento) e diferenciou os dois grupos com sensibilidade de 67 por cento e especificidade de 76 por cento. CONCLUSÕES: 1) as amilasemias e lipasemias não diferenciaram os dois grupos avaliados; 2) relação lipase/amilase >3 é mais freqüente na pancreatite aguda/pancreatite crônica agudizada alcoólica do que na pancreatite aguda biliar, e pode ser útil na diferenciação destas duas causas de pancreatite.

BACKGROUND: Alcoholic or biliary acute pancreatitis may need different therapeutic approaches. AIM: Assessing the validity of lipase/amylase ratio in differentiating biliary from alcoholic acute pancreatitis/acutized chronic pancreatitis. METHODS: Nine male patients (mean age and standard deviation: 39.8 ± 7.0 years) with alcoholic acute pancreatitis/acutized chronic pancreatitis (group I) and 29 patients, 8 male and 21 female (mean age: 43.6 ± 19.9 years), with biliary acute pancreatitis (group II) were evaluated. Serum lipase and amylase levels were measured in patients with symptoms for no more than 48 hours. The lipase/amylase ratio was calculated based on serum lipase and amylase levels and expressed as multiples of their respective superior reference values. RESULTS: Mean levels of serum lipase (4,814 ± 3,670 U/L) and amylase (1,282 ± 777 U/L) in patients of group I were comparable to group II (2,697 ± 2,391 and 1,878 ± 1,319 U/L, respectively), but the mean lipase/amylase ratio was significantly higher in group I (4.4 ± 3.6) than in group II (2.2 ± 2.2). Lipase/amylase ratio >3 occurred at significantly higher proportions in patients of group I (66.7 percent) than of group II (24.1 percent), differentiating the two groups with sensitivity of 67 percent and specificity of 76 percent. CONCLUSIONS: 1) Amylase and lipase serum levels did not differ in the two groups evaluated; 2) the lipase/amylase ratio >3 was more often seen in alcoholic acute pancreatitis/acutized chronic pancreatitis than biliary acute pancreatitis, and it may be useful in differentiating these two causes of pancreatitis.

Validade da amilasemia e da lipasemia no diagnóstico diferencial entre pancreatite aguda/crônica agudizada e outras causas de dor abdominal aguda / Validity of serum amylase and lipase for the differential diagnosis between acute/acutized chronic pancreatitis and other causes of acute abdominal pain

RACIONAL: Várias doenças abdominais podem cursar com aumento de amilasemia e lipasemia. OBJETIVO: Avaliar a validade da amilasemia e lipasemia para os diagnósticos diferenciais entre pancreatite aguda/pancreatite crônica agudizada, doenças das vias biliares, úlcera gastroduodenal perfurada e apendicite aguda. PACIENTES E MÉTODOS: Foram avaliados, prospectivamente, 38 pacientes com pancreatite aguda/pancreatite crônica agudizada, 35 com doenças das vias biliares, 17 com úlcera gastroduodenal perfurada e 44 com apendicite aguda, com idade média (desvio padrão) de 42,4 ± 17,7, 46,7 ± 18,3, 47,8 ± 12 e 33,7 ± 17,8 anos, respectivamente. A amilasemia e a lipasemia foram determinadas à admissão no pronto-socorro. RESULTADOS: Para o diagnóstico de pancreatite aguda/pancreatite crônica agudizada, quando o nível de corte da amilasemia variou entre o limite superior de referência e 5 vezes este limite, a sensibilidade diminuiu de 92 por cento para 74 por cento, a especificidade aumentou de 85 por cento para 99 por cento, o valor preditivo positivo aumentou de 71 por cento para 97 por cento e o valor preditivo negativo diminuiu de 96 por cento para 91 por cento. Para a lipasemia valores semelhantes foram obtidos para sensibilidade e valor preditivo negativo, mas a especificidade e o valor preditivo positivo foram mais baixos. Quando se considerou amilasemia ou lipasemia elevadas, houve pequeno aumento na sensibilidade e no valor preditivo negativo. CONCLUSÕES: Para o diagnóstico de pancreatite aguda/pancreatite crônica agudizada, 1) o melhor nível de corte para ambos os testes foi o de duas vezes o limite superior de referência; 2) as sensibilidades da amilasemia e da lipasemia foram semelhantes; 3) a especificidade e o valor preditivo positivo da amilasemia foram ligeiramente maiores do que as da lipasemia; 4) a sensibilidade, mas não a especificidade, aumentou quando pelo menos uma das enzimas estava elevada.

Actualización en pancreatitis aguda: Hospital Dr. Gustavo Fricke 1997-2001 / Updating in acute pancreatitis: Hospital Dr. Gustavo Fricke 1997-2001

El diagnóstico adecuado de pancreatitis aguda (P.A.) leve o grave tiene gran implicancia pronóstica y terapéutica. Se realizó un estudio retrospectivo-comparativo, desde 1997 al 2001, obteniendo una muestra de 170 fichas clínicas correspondientes al Hospital Dr. G. Fricke, selecionadas azarosamente, con diagnóstico de egreso de "Pancreatitis Aguda". Se evaluó la clínica al ingreso, exámenes de laboratorio, TAC de abdomen según la clasificación de Balthazar y evolución de la enfermedad. Encontramos u 67.3 por ciento de P.A. leves y 32.7 por ciento graves.

Atividades hidrolíticas de amostras de conteúdo do intestino delgado de bovinos adultos, infectados ou näo por Eurytrema sp, determinadas por difusäo radial enzimática / Hydrolytic activities of small intestine content as determined by radial enzyme diffusion in Eurytrema sp infected or non infected cattle

Empregando-se difusäo radial enzimática em ágargel, atividades hidrolíticas de amostras de conteúdo do intestino delgado de 38 bovinos adultos de matadouro foram mensuradas em animais agrupados como possuidores de pâncreas hígidos (controle) e parasitados por Eurytrema sp, estes, segundo dois graus de infecçäo reconhecidos. Para tal, foram empregados quatro substratos, dos quais caseinato de cálcio e óleo de milho tiveram de ser desconsiderados porque, no caso deles, näo houve formaçäo de halos ou estes apresentaram limites imprecisos. Apesar desses problemas näo terem ocorrido quando o substrato era leite em pó desnatado ou amido, as atividades hidrolíticas encontradas foram equivalentes, independentemente da condiçäo de parasitismo e grau de infecçäo verificados (P>0,05). Concluiu-se, entäo, que a técnica de difusäo radial enzimática, pelo menos com os substratos empregados, foi incapaz de acusar disfunçöes pancreáticas exócrinas em bovinos infectados por Eurytrema sp.

Lúpus eritematoso sistêmico: vasculite necrosante, tipo poliarterite nodoso, determinando pancreatite crônica / Systemic lupus erythematous: necrotizing vasculitis, polyarteritis nodosa-like

O LES afeta múltiplo orgäos e sistemas. Lesäo pancreática é rara, ocorrendo geralmente associada à doença com intensa atividade e envolvimento de vários orgäos. Relatamos um caso de paciente de 27 anos que foi ao óbito após um quadro de dor abdominal e hiperamilasemia. Na autopsia, observamos vasculite sistêmica necrosante, do tipo poliarterite nodosa, comprometendo particularmente o pâncreas e determinando pancreatite crônica calcificante. Os autores discutem a evoluçäo incomum e o papel da vasculite na patogênese das lesöes pancreáticas no LES

Pancreatitis crónica juvenil / Juvenile chronic pancreatitis

Introducción: la pancreatitis crónica juvenil se considera una enfermedad de baja frecuencia que provoca importante sintomatología y cuyo tratamiento es controversial. Objetivo: conocer nuestra experiencia en el manejo de la pancreatitis crónica juvenil. Personas y método: se evaluó arbitrariamente a la población menor de 30 años con evidencias de pancreatitis crónica, diagnosticada conforme a los criterios de la Sociedad Japonesa de Páncreas, entre 1994 y 1999 en el Hospital Regional de Temuco y Clínica Alemana de Temuco. Se revisaron retrospectivamente las historias clínicas, obteniendo los datos clínicos, de laboratorio, imagenológicos y los procedimientos terapéuticos efectuados. Para el seguimiento se elaboró una encuesta la que fue aplicada a cada paciente. Resultados: se detectaron 7 pacientes con pancreatitis crónica dentro el rango de 15 a 30 años. La etiología fue clasificada como idiopática en 3 pacientes, 1 de tipo familiar, 1 alcohólica mientras que en 2 se confirmó el diagnóstico de Pancreas Divisum. La pancreatografía mostró alteraciones en el 100 por ciento de los pacientes. En dos pacientes se realizaron procedimientos terapéuticos endoscópicos, en uno con Páncreas Divisum incompleto, se realizó una esfinterotomía de la papila menor, en otro, con estenósis de la papila menor, en otro, con estenósis de la papila principal, se realizó también esfinterotomía endoscópica. Se sometieron a tratamiento quirúrgico tres pacientes. Un paciente con Pancreas Divisum completo, se sometió a una esfinteroplastía transduodenal de la papila menor. En los otros, con dolor intratable, y que tenía un conducto pancreático de un calibre mayor a 5 mm, se realizó una pancreaticoyeyunoanastomosis. Ningún paciente presentó complicaciones. Sólo dos pacientes permanecen con tratamiento médico (régimen y enzimas pancreáticas). El seguimiento más alejado alcanzó los 48 meses. Sólo en los 5 pacientes, en que se realizó algún procedimiento terapéutico, hubo una disminución significativa del dolor. Conclusiones: la pancreatitis crónica representa una causa a considerar frente a un paciente portador de un cuadro doloroso abdominal aun cuando este sea menor de 30 años. Los factores etiopatogénicos se clasifican en su mayoría como idiopáticos, sin embargo el páncreas divisum debe ser siempre considerado. El manejo dependerá fundamentalmente del estado del conducto pancreático, obteniéndos buenos resultados cuando la terapia se selecciona conforme a cada caso

Pancreatitis crónica: una experiencia nacional reciente de su manejo quirúrgico / Surgical management of chronic pancreatitis: a national experience

The charts of 17 patients (12 male), aged 7 to 65 years old, with chronic pancreatitis that were operated in three different Chilean regions, were reviewed. Results: Seven patients had previous endoscopic therapeutic procedures (papillotomy in 4 and stent placint in 3). Seven patients had been subjected to previous biliary surgical procedures. Indications for surgery were severe pain in 14 patients, the suspicion of a pancreatic carcinoma in 4 patients, an infected pseudocyst in one and massive bleeding of multiple pseudo-aneurysms in a pseudocysts in one patient. Twelve patients were subjected to decompressions and 5 to pancreatic resections. There was no operative mortality and one transient pancreatic fistula. After an average follow up of 22 months, pain improved in 94 percent of cases, pancreatic cancer was diagnosed in one patient and 79 percent of subjects gained weight. One patient became insulin dependent, one increased his insulin requirements and one bad transient steatorrhea, since she could not afford pancreatic enzyme replacement therapy. Conclusions: The multidisciplinary approach of patients with chornic pancreatitis, with selective use of surgery, may greatly improve their quelity of life