A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome

Retrocrural space involvement on computed tomography as a predictor of mortality and disease severity in acute pancreatitis

Background

Because computed tomography (CT) has advantages for visualizing the manifestation of necrosis and local complications, a series of scoring systems based on CT manifestations have been developed for assessing the clinical outcomes of acute pancreatitis (AP), including the CT severity index (CTSI), modified CTSI, etc. Despite the internationally accepted CTSI having been successfully used to predict the overall mortality and disease severity of AP, recent literature has revealed the limitations of the CTSI. Using the Delphi method, we establish a new scoring system based on retrocrural space involvement (RCSI), and compared its effectiveness at evaluating the mortality and severity of AP with that of the CTSI.

Methods

We reviewed CT images of 257 patients with AP taken within 3–5 days of admission in 2012. The RCSI scoring system, which includes assessment of infectious conditions involving the retrocrural space and the adjacent pleural cavity, was established using the Delphi method. Two radiologists independently assessed the RCSI and CTSI scores. The predictive points of the RCSI and CTSI scoring systems in evaluating the mortality and severity of AP were estimated using receiver operating characteristic (ROC) curves.

Principal Findings

The RCSI score can accurately predict the mortality and disease severity. The area under the ROC curve for the RCSI versus CTSI score was 0.962±0.011 versus 0.900±0.021 for predicting the mortality, and 0.888±0.025 versus 0.904±0.020 for predicting the severity of AP. Applying ROC analysis to our data showed that a RCSI score of 4 was the best cutoff value, above which mortality could be identified.

Conclusion

The Delphi method was innovatively adopted to establish a scoring system to predict the clinical outcome of AP. The RCSI scoring system can predict the mortality of AP better than the CTSI system, and the severity of AP equally as well.

Pancreatitis-imaging approach

Pancreatitis is defined as the inflammation of the pancreas and considered the most common pancreatic disease in children and adults. Imaging plays a significant role in the diagnosis, severity assessment, recognition of complications and guiding therapeutic interventions. In the setting of pancreatitis, wider availability and good image quality make multi-detector contrast-enhanced computed tomography (MD-CECT) the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization. This article reviews the proposed definitions of revised Atlanta classification for acute pancreatitis, illustrates a wide range of morphologic pancreatic parenchymal and associated peripancreatic changes for different types of acute pancreatitis. It also describes the spectrum of early and late chronic pancreatitis imaging findings and illustrates some of the less common types of chronic pancreatitis, with special emphasis on the role of CT and MRI.

Single-portal-phase low-tube-voltage dual-energy CT for short-term follow-up of acute pancreatitis: evaluation of CT severity index, interobserver agreement and radiation dose

OBJECTIVES

To intra-individually compare single-portal-phase low-tube-voltage (100-kVp) computed tomography (CT) with 120-kVp images for short-term follow-up assessment of CT severity index (CTSI) of acute pancreatitis, interobserver agreement and radiation dose.

METHODS

We retrospectively analysed 66 patients with acute pancreatitis who underwent initial dual-contrast-phase CT (unenhanced, arterial, portal phase) at admission and short-term (mean interval 11.4 days) follow-up dual-contrast-phase dual-energy CT. The 100-kVp and linearly blended images representing 120-kVp acquisition follow-up CT images were independently evaluated by three radiologists using a modified CTSI assessing pancreatic inflammation, necrosis and extrapancreatic complications. Scores were compared with paired t test and interobserver agreement was evaluated using intraclass correlation coefficients (ICC).

RESULTS

Mean CTSI scores on unenhanced, portal- and dual-contrast-phase images were 4.9, 6.1 and 6.2 (120 kVp) and 5.0, 6.0 and 6.1 (100 kVp), respectively. Contrast-enhanced series showed a higher CTSI compared to unenhanced images (P < 0.05) but no significant differences between single- and dual-contrast-phase series (P > 0.7). CTSI scores were comparable for 100-kVp and 120-kVp images (P > 0.05). Interobserver agreement was substantial for all evaluated series and subcategories (ICC 0.67-0.93). DLP of single-portal-phase 100-kVp images was reduced by 41 % compared to 120-kVp images (363.8 versus 615.9 mGy cm).

CONCLUSIONS

Low-tube-voltage single-phase 100-kVp CT provides sufficient information for follow-up evaluation of acute pancreatitis and significantly reduces radiation exposure.

KEY POINTS

• Single-portal-phase CT provides sufficient evaluation for follow-up of acute pancreatitis. • Follow-up CT does not benefit from unenhanced or arterial-phase acquisition. • CT severity index scores are equal for dual-contrast-phase 100-/120-kVp acquisition (P > 0.05). • 100-kVp single-portal-phase follow-up CT of acute pancreatitis significantly reduces radiation exposure.

Acute necrotizing pancreatitis: laboratory, clinical, and imaging findings as predictors of patient outcome

OBJECTIVE

In patients with acute necrotizing pancreatitis, we analyzed whether laboratory and clinical findings determined in the early phase of disease and morphologic features on contrast-enhanced CT (CECT) at the beginning of the late phase of disease are helpful in predicting patient outcome and whether CECT findings provide additional information in establishing prognosis compared with the laboratory and clinical findings.

MATERIALS AND METHODS

A retrospective analysis of 99 patients with acute necrotizing pancreatitis was performed. Four laboratory variables (albumin, calcium, C-reactive protein, WBC count) and three clinical variables (Acute Physiology, Age, Chronic Health Evaluation [APACHE] II score; Simplified Acute Physiology Score [SAPS] II; persistent organ failure) were assessed. Five morphologic features on CECT including Balthazar grade and CT severity index were reviewed. The endpoints of patient outcome were peripancreatic or pancreatic infection, need for intervention, duration of organ failure, ICU and hospital stays, and death. Based on receiver operating characteristic curve analysis for infection, high-and low-risk groups for each prognostic variable were calculated and univariable and multivariable Cox regression analyses were carried out.

RESULTS

In our study population of 99 patients (63 men, 36 women; median age, 52 years; age range, 18-84 years), 25 patients (25%) developed infection, 42 patients (42%) experienced organ failure, and 12 patients (12%) died. Regarding the laboratory and clinical variables, albumin level, APACHE II score, and particularly persistent organ failure were the strongest independent predictors of patient outcome. Regarding the imaging variables, Balthazar grade and a morphologic feature that takes the distribution of intrapancreatic necrosis into account were the strongest independent predictors. In the multivariable analysis of all studied variables, imaging variables were independent and strong predictors of patient outcome and provided additional information in establishing prognosis compared with clinical and laboratory findings.

CONCLUSION

In patients with suspected or proven acute necrotizing pancreatitis, performing CECT at the beginning of the late phase of disease is recommended to identify patients at increased risk for adverse outcomes.

Abdominal compartment syndrome in acute pancreatitis: a systematic review

Abdominal compartment syndrome (ACS) is a lethal complication of acute pancreatitis. We performed a systematic review to assess the treatment and outcome of these patients.A systematic literature search for cohorts of patients with acute pancreatitis and ACS was performed. The main outcomes were number of patients with ACS, radiologic and surgical interventions, morbidity, mortality, and methodological quality.After screening 169 articles, 7 studies were included. Three studies were prospective and 4 studies were retrospective. The overall methodological quality of the studies was moderate to low. The pooled data consisted of 271 patients, of whom 103 (38%) developed ACS. Percutaneous drainage of intraabdominal fluid was reported as first intervention in 11 (11%) patients. Additional decompressive laparotomy was performed in 8 patients. Decompressive laparotomy was performed in a total of 76 (74%) patients. The median decrease in intraabdominal pressure was 15 mm Hg (range, 33-18 mm Hg). Mortality in acute pancreatitis patients with ACS was 49% versus 11% without ACS. Morbidity ranged from 17% to 90%.Abdominal compartment syndrome during acute pancreatitis is associated with high mortality and morbidity. Studies are relatively small and have methodological shortcomings. The optimal timing and method of invasive interventions, as well as their effect on clinical outcomes, should be further evaluated.

Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification

BACKGROUND

Recent international multidisciplinary consultation proposed the use of local (sterile or infected pancreatic necrosis) and/or systemic determinants (organ failure) in the stratification of acute pancreatitis. The present study was to validate the moderate severity category by international multidisciplinary consultation definitions.

METHODS

Ninety-two consecutive patients with severe acute pancreatitis (according to the 1992 Atlanta classification) were classified into (i) moderate acute pancreatitis group with the presence of sterile (peri-) pancreatic necrosis and/or transient organ failure; and (ii) severe/critical acute pancreatitis group with the presence of sterile or infected pancreatic necrosis and/or persistent organ failure. Demographic and clinical outcomes were compared between the two groups.

RESULTS

Compared with the severe/critical group (n=59), the moderate group (n=33) had lower clinical and computerized tomographic scores (both P<0.05). They also had a lower incidence of pancreatic necrosis (45.5% vs 71.2%, P=0.015), infection (9.1% vs 37.3%, P=0.004), ICU admission (0% vs 27.1%, P=0.001), and shorter hospital stay (15+/-5 vs 27+/-12 days; P<0.001). A subgroup analysis showed that the moderate group also had significantly lower ICU admission rates, shorter hospital stay and lower rate of infection compared with the severe group (n=51). No patients died in the moderate group but 7 patients died in the severe/critical group (4 for severe group).

CONCLUSIONS

Our data suggest that the definition of moderate acute pancreatitis, as suggested by the international multidisciplinary consultation as sterile (peri-) pancreatic necrosis and/or transient organ failure, is an accurate category of acute pancreatitis.

Imaging of acute pancreatitis and its complications. Part 2: complications of acute pancreatitis

The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Major changes include subdividing acute fluid collections into "acute peripancreatic fluid collection" and "acute post-necrotic pancreatic/peripancreatic fluid collection (acute necrotic collection)" based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into "pseudocyst" and "walled of pancreatic necrosis". Appropriate use of the new terms describing the fluid collections is important for management decision-making in patients with acute pancreatitis. The purpose of this review article is to present an overview of complications of the acute pancreatitis with emphasis on their prognostic significance and impact on clinical management and to clarify confusing terminology for pancreatic fluid collections.

Imaging of acute pancreatitis and its complications. Part 1: acute pancreatitis

Acute pancreatitis is an acute inflammatory disease of the pancreas that may also involve surrounding tissues or remote organs. The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Generally, imaging is recommended to confirm the clinical diagnosis, investigate the etiology, and grade the extend and severity of the acute pancreatitis. Ultrasound is the first-line imaging modality in most centers for the confirmation of the diagnosis of acute pancreatitis and the ruling out of other causes of acute abdomen, but it has limitations in the acute clinical setting. Computed tomography not only establishes the diagnosis of acute pancreatitis, but also enables to stage severity of the disease. Magnetic resonance imaging has earned an ever more important role in the diagnosis of acute pancreatitis. It is especially useful for imaging of patients with iodine allergies, characterizing collections and assessment of an abnormal or disconnected pancreatic duct. The purpose of this review article is to present an overview of the acute pancreatitis, clarify confusing terminology, underline the role of ultrasound, computed tomography and magnetic resonance imaging according to the proper clinical context and compare the advantages and limitations of each modality.

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

OBJECTIVE

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

DESIGN

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

RESULTS

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2-9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1-23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

CONCLUSIONS

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.

Acute pancreatitis associated with molecular targeted therapies: a retrospective review of the clinico-radiological features, management and outcome

PURPOSE

To study the presentation, radiological features, management and outcome of acute pancreatitis detected on imaging in patients receiving molecular targeted therapy (MTT).

MATERIALS AND METHODS

In this IRB-approved, HIPAA-compliant retrospective study, search of the radiology database from January 2005 through September 2012 revealed 91 cancer patients with radiologic evidence of acute pancreatitis. Of these, 15 patients receiving MTT (7 women, 8 men; mean age 59 years, range 25-84 years) and fulfilling the criteria of acute pancreatitis without any confounding factors were included. Imaging at initial diagnosis of pancreatitis and subsequently were reviewed by three radiologists in consensus; clinical presentation, management, and outcome were documented from the medical record.

RESULTS

Eleven patients had focal and four had diffuse pancreatitis. The tail of the pancreas (n = 6) was the most common site of focal pancreatitis. Of the 14/15 patients who underwent CT, modified CT severity index was 2 in 12 patients and 4 in 2 patients. One patient (1/15) who underwent only FDG-PET/CT showed focal pancreatitis. None of the patients had pancreatic necrosis or peripancreatic collections. Findings resolved in all the patients after discontinuation of MTT, except in one patient who died of progressive disease. No radiological or surgical interventions were required in any of the patients. Findings recurred in 4/9 patients (44%) in whom MTT was restarted.

CONCLUSION

MTT-associated pancreatitis is usually mild, focal, and managed conservatively with discontinuation of MTT. The imaging findings are subtle and in our study, pancreatitis recurred in 44% of patients after restarting MTT.

The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines

Imaging of acute pancreatitis requires not only an understanding of the disease subtypes and the myriad of associated complications but also familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, by the Acute Pancreatitis Classification Working Group in 2008. The accurate description of the radiological findings plays a critical role in the evaluation and management of patients with acute pancreatitis, particularly those with severe disease. There have been increasing efforts to develop uniformity in the use of terminology used to define the radiologic findings in acute pancreatitis, in particular, the terminology for fluid collections, a common area of inconsistency and confusion. Terms such as "acute peripancreatic fluid collections," "acute post- necrotic fluid collections," "pseudocyst," and "walled-off pancreatic necrosis" are now recommended as they describe the evolution of fluid collections in patients with both interstitial and necrotizing pancreatitis and nonspecific terms such as "pancreatic abscess" and "phlegmon" are being abandoned. In this review we illustrate, with case examples, the standardized terminology used in the radiological and clinical description of acute pancreatitis, its severity, and complications with an emphasis on the role of ultrasound, computed tomography and magnetic resonance imaging. Different management options of the associated complications are also discussed. The use of standardized terminology will hopefully improve the communication between radiologists, gastroenterologists, and surgeons to facilitate treatment planning and will lead to enhanced outcomes for patients with acute pancreatitis as well as create uniformity for enrollment into research studies.

Scoring of human acute pancreatitis: state of the art

BACKGROUND

Acute pancreatitis remains as one of the most difficult and challenging digestive disorder to predict in terms of clinical course and outcome. Every case has an individual course and therefore acute pancreatitis remains challenging and fascinating. Due to this variability, many different scoring systems have evolved during the last decades. Every scoring system has advantages and disadvantages. Not every scoring system is capable of assessing the clinical time course of the disease, some are only suitable for the time of initial presentation.

AIM

This paper will give an overview on the development of different widely used scoring systems and their performance in assessing severity and prognosis of acute pancreatitis.

CONCLUSION

Severity assessment means objective quantification of overall severity of illness. Early and reliable stratification of severity is required to decide best treatment of the individual patient, preparation for possible evolving complications or for referral to specialist centers. No single scoring system is able to cover the entire range of problems associated with treatment and assessment of acute pancreatitis. In our clinical experience, we recommend hematocrit upon admission, daily sequential organ failure assessment score and procalcitonin, C-reactive protein on day 3 and CT severity index beyond the first week. These scoring tools together with close clinical follow-up of the patient ultimately lead to an optimized treatment of this challenging disease.

Prognostic value of acute fluid collections diagnosed by ultrasound in the early assessment of severity of acute pancreatitis

PURPOSE

To evaluate the prognostic value of acute fluid collections (AFC) diagnosed by conventional transabdominal ultrasound in the early assessment of severity acute pancreatitis (AP).

METHODS

We studied 128 consecutive patients with AP between March 2006 and March 2011. The predictor was the number of AFC. Outcome measure was the occurrence of complications. Abdominal sonogram, contrast-enhanced CT, and pancreatitis-specific clinical and laboratory findings were performed.

RESULTS

AFC were associated with complications (p < 0.0001), Balthazar grade (p = 0.004), Ranson score (p < 0.0001), and the majority of clinical, radiologic, and biochemical parameters for predicting complications of AP (p < 0.05). Univariate logistic regression also revealed significant association between the number of AFC and the occurrence of complications (OR 4.4; 95% CI 2.5-7.6). After the adjustment for covariates, AFC remained prognostic for complications and a cutoff point of >1 AFC was prognostic of their occurrence with 88% sensitivity and 82% specificity.

CONCLUSIONS

AFC are related to the clinical course of AP and can predict its severity

Predictors of adverse outcomes in acute pancreatitis: new horizons

Acute pancreatitis (AP) continues to be a clinical challenge. The mortality of patients with AP with adverse outcomes like organ failure and infected necrosis can be as high as 43 %. Highly accurate predictors of adverse outcomes are necessary to identify the high-risk patients so that they can be meticulously monitored and managed. However, there are no ideal predictors till date. Over the past several years, a number of single- and multi-parameter predictors have been identified and tested for prediction of adverse outcomes in AP. Out of the different tools tested, blood urea nitrogen and the harmless acute pancreatitis score appears to be useful and feasible in the management of AP under Indian conditions. Other single-parameter predictors like serum creatinine, hematocrit, erythrocyte sedimentation rate, C-reactive protein, and D-dimer need to be put to further tests in high-quality prospective studies with large sample size at the community level. Multi-parameter prediction tools like the bedside index of severity of acute pancreatitis may not be appealing in day-to-day clinical practice.

Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach

BACKGROUND

Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear.

METHODS

In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication.

RESULTS

Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%.

CONCLUSIONS

PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.

To Study the Clinical, Biochemical and Radiological Features of Acute Pancreatitis in HIV and AIDS

Background

Pancreatitis complicating HIV infection, even in the Highly Active Antiretroviral Therapy (HAART) era, remains a management challenge. We felt there is a need to discern patterns in the biochemical markers, radiological studies, co-infections, length of stay (LOS) in patients with HIV or AIDS AND pancreatitis.

Methods

This is a retrospective study conducted from June, 2008 to August, 2010 on patients admitted with acute pancreatitis to our hospital. We extracted and compared the following parameters: biochemical markers, HBV markers (surface antigen, core antibody and surface antibody), HCV antibody, radiological studies, and length of stay (LOS). The Balthazar Grade score was used to assess radiological severity of disease. We stratified the cohort into comparison subsets according to CD4 count.

Results

Ninety-four admissions met the criteria for HIV or AIDS AND pancreatitis; 67 unique patients comprised the cohort. Median age was 48 years (range, 23 to 60 years). Thirty seven (55%) were male, 30 (45%), female. Two third (n = 51) (76%) were African American. Known risk factors included a history of pancreatitis, 17 (25%); cholecystitis, 13 (19%); alcohol abuse, 25 (37%); Intravenous drug abuse, 18 (27%). Only 36 (38%) admissions were on HAART regimen. Biochemical features on admission were: WBC, 6,100/mm³ (900 - 25,700); amylase, 152 U/L (30 - 1,344); lipase, 702.5 U/L (30 - 5,766), triglyceride, 65 mg/dL (57 - 400); glucose, 94 mg/dL (60 - 1,670); lactate, 2.3 mmol/L (1.09 - 5.49); AST, 61.5 U/L (9 - 1,950); LDH, 762 U/L (394 - 5,500); bicarbonate 19.5 mEq/L (3.3 - 82.7). Interestingly, 62% patients had normal pancreas on CT scan on admission. Of 67 individuals, hepatitis profile was available in 43, 21 (49%) were positive for HCV, 11 (26%) had markers for HBV. Four of 11 patients (36) with CD4 < 50 had evidence of persistent HBV (+core, -surface ab). Patients with CD4 < 200 have a median time for hospital course of 8 days (range 4 - 61 days) compare to 3 days in patients with CD4 > 200. P = 0.03 via t-test comparison. One patient with CD4 < 50 died due to acute pancreatitis.

Conclusion

Pancreatitis remains a major cause of morbidity in HIV-infected individuals. This study has provided detailed features in the HAART therapy era about the clinical, biochemical and radiological features of pancreatitis. Half of our patients were positive for HCV; additionally, 36% with CD4 < 50 had persistent HBV. As opposed to earlier studies, we did not find a female predominance. Patients with CD4 < 200 had a 2.67-fold increase length of stay. Future studies are needed for a closer look on viral cofactors which might precipitate episodes of acute pancreatitis.

Conceptual framework for classifying the severity of acute pancreatitis

Acute pancreatitis has been known as a distinct clinical entity since the end of the 19th century, but its management is still characterised by an absence of specific treatments, despite extensive clinical and experimental research. In part this has stemmed from the limitations of the classifications for acute pancreatitis severity used so far. It may well be that the perpetual use of classifications which were solely based on empirical description of severity has retarded progress in the field due to systematic misclassification in selecting patients for clinical trials, evaluating the effects of treatment, and comparing the inter-institutional data. This article considers several important questions with regard to classifying the severity of acute pancreatitis. These relate to how the classification is best used, what determines the severity of acute pancreatitis, how determinants relate to each other and the time course of determinants. Further, the concept of causal inference is applied to classifying the severity of acute pancreatitis, and the best available evidence suggests that classification of acute pancreatitis severity should be based on local and systemic determinants. It is anticipated that the determinants-based classification of acute pancreatitis severity will underpin the ability of future research to discover a specific treatment for acute pancreatitis and make routine clinical management of patients with acute pancreatitis more tailored and evidence-based.

Acute pancreatitis secondary to gestational hypertriglyceridaemia

Gestational hypertriglyceridaemia is a rare cause of acute pancreatitis. Its pathophysiology is incompletely understood. Severity scoring and effective management remain challenging. We report a case of acute pancreatitis secondary to gestational hypertriglyceridaemia. We describe the use of computed tomography to provide an alternative determination of severity, as well as plasmapheresis as a means of treating the condition.

Correlates of morbidity and mortality in severe necrotizing pancreatitis

Acute severe pancreatitis is associated with a high morbidity and mortality and frequently is accompanied by underlying pancreatic parenchymal necrosis. Patients with pancreatic necrosis must be identified, because the morbidity and mortality rate in this subgroup is much higher. Our objective was to compare the clinical outcomes of these patients based on the degree of pancreatic necrosis. A total of 35 patients were noted to have pancreatic necrosis. These were divided into 2 groups based on extent of necrosis: group A had less than 50% necrosis and group B had more than 50% necrosis. The rate of mortality (5% versus 40%) was significantly higher in group B. The rate of organ dysfunction also rose along with the rates of other morbidities and variables that were related to a patient's hospital stay. Only APACHE II significantly correlated with the degree of necrosis, wherein the chances of substantial necrosis rose by 20% with each unit increase of APACHE II score. APACHE II Score could be employed and studied further prospectively to help identify patients with pancreatic necrosis.

Epidemiological characteristic of acute pancreatitis in Trzebnica district

Acute pancreatitis is one of the most common surgical disease, and thus cause of hospitalization. Incidence and etiology of this condition demonstrates large regional differences. This situation is a substantial financial burden forhospital district, and changes in organization structure and funding medical service should be taken under consideration.The aim of the study was to record the epidemiology with etiology, diagnosis and treatment of acute pancreatitis in large district (77 000 inhabitants).Material and methods. A meta-analysis study of all 298 patients admitted to Hospital St Hedwig in Trzebnica, in the six-year period from 2005 to 2010, with acute pancreatitis was performed.Results. Acute pancreatitis was diagnosed in 298 patients in the six - year period, giving an estimated incidence of 64.4 per 100 000. Among the group of 441 admissions for acute pancreatitis in 298 patients was confirmed. Severe acute pancreatitis developed in 22.5% (67/298) of patients, more often in males 56/208 (27%) than in females 11/90 (12%). Gallstones were found as an etiological factor in 27% (80/298), and alcohol intake in 49% of patients. 211/298 (70%) patients had only one attack, whereas 29% (87/298) were readmitted with 230 relapses. The risk of recurrent pancreatitis was 48% in alcohol induced and 6,25% in gallstone induced pancreatitis. 53/298 patients (17%) were operated, ERCP procedures were performed in 24.Performed operations: necrosectomy in 25/53 (47%), elective cholecystectomy in 16/53 (30%), open drainage of abdominal abscess in 5/53 (9%), open drainage of cysts in 5/53 (9%), Jurasz's operation in 2/53 (3%). Majority surgical treatment was carried out in 68% cases with severe acute pancreatitis. Mortality due to acute pancreatitis was 3% (10/298); 15% in severe pancreatitis.Conclusions. 1. Acute pancreatitis continues to be an important clinical problem. 2. Severe, necrotic acute pancreatitis is associated with high mortality rates. 3. The ethanol-intake-related episodes of acute pancreatitits are much more prevalent than the gall-stone-related ones. 4. After the exclusion of ethanol- and gall-stones-related etiologies, the subsequent diagnostic process should aim at excluding neoplastic process of the head of pancreas.

A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis

OBJECTIVES

The early identification of clinically severe acute pancreatitis (AP) is critical for the triage and treatment of patients. The aim of this study was to compare the accuracy of computed tomography (CT) and clinical scoring systems for predicting the severity of AP on admission.

METHODS

Demographic, clinical, and laboratory data of all consecutive patients with a primary diagnosis of AP during a two-and-half-year period was prospectively collected for this study. A retrospective analysis of the abdominal CT data was performed. Seven CT scoring systems (CT severity index (CTSI), modified CT severity index (MCTSI), pancreatic size index (PSI), extrapancreatic score (EP), ''extrapancreatic inflammation on CT'' score (EPIC), ''mesenteric oedema and peritoneal fluid'' score (MOP), and Balthazar grade) as well as two clinical scoring systems: Acute Physiology, Age, and Chronic Health Evaluation (APACHE)-II and Bedside Index for Severity in AP (BISAP) were comparatively evaluated with regard to their ability to predict the severity of AP on admission (first 24 h of hospitalization). Clinically severe AP was defined as one or more of the following: mortality, persistent organ failure and/or the presence of local pancreatic complications that require intervention. All CT scans were reviewed in consensus by two radiologists, each blinded to patient outcome. The accuracy of each imaging and clinical scoring system for predicting the severity of AP was assessed using receiver operating curve analysis.

RESULTS

Of 346 consecutive episodes of AP, there were 159 (46%) episodes in 150 patients (84 men, 66 women; mean age, 54 years; age range, 21-91 years) who were evaluated with a contrast-enhanced CT scan (n = 131 episodes) or an unenhanced CT scan (n = 28 episodes) on the first day of admission. Clinically severe AP was diagnosed in 29/159 (18%) episodes; 9 (6%) patients died. Overall, the Balthazar grading system (any CT technique) and CTSI (contrast-enhanced CT only) demonstrated the highest accuracy among the CT scoring systems for predicting severity, but this was not statistically significant. There were no statistically significant differences between the predictive accuracies of CT and clinical scoring systems.

CONCLUSIONS

The predictive accuracy of CT scoring systems for severity of AP is similar to clinical scoring systems. Hence, a CT on admission solely for severity assessment in AP is not recommended.

Variability of CT contrast enhancement in the pancreas: a cause for concern?

BACKGROUND

Multidetector CT is a valuable technique for diagnosis/staging in several pancreatic pathologies. Diagnosis is usually based on tissue density measurements. Recently, newer functional CT techniques have been introduced. The aim of this study was to assess variability in perfusion and dual-energy CT data, and to compare these data with density measurements in the pancreas of a healthy population.

METHODS

Two groups were included: 20 patients underwent perfusion CT imaging, and 10 patients were scanned using a dual-energy protocol. In both groups, tissue density [Hounsfield units (HU)] was measured in the pancreatic head, body and tail. Functional data were calculated (blood flow/blood volume in the perfusion CT group, iodine concentration in the dual-energy group), and variability was assessed.

RESULTS

Density measurements were comparable for the perfusion and dual-energy CT groups, and ranged from 14 to 60 HU. Maximal enhancement differences between the head/body/tail of the pancreas ranged between 2 and 21 HU. Considerable variability was observed, both in density measurements (ranging from 3 to 34%) and in functional parameters (mean variability in perfusion CT parameters blood flow and blood volume was 21.3 and 10% respectively; mean variability in dual-energy iodine-mapping results was 24.4%).

CONCLUSION

This study demonstrated the presence of important intraindividual variability in pancreatic tissue contrast enhancement, regardless of the CT technique used. Considering the variability observed in this study, the use of cut-off values to characterize pancreatic pathologies seems troublesome, and morphologic primary and secondary changes will remain important, even when using novel functional imaging techniques. and IAP.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Management of severe acute pancreatitis

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis. Severity of acute pancreatitis is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis. Risk factors independently determining the outcome of SAP are early multiorgan failure (MOF), infection of necrosis, and extended necrosis (>50%). Morbidity of SAP is biphasic, in the first week it is strongly related to systemic inflammatory response syndrome while, sepsis due to infected pancreatic necrosis leading to MOF syndrome occurs in the later course after the first week. Contrast-enhanced computed tomography provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or are at risk for developing a severe disease require early intensive care treatment. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis are candidates for intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased to below 20% in high-volume centers.

Prediction of severe acute pancreatitis using classification and regression tree analysis

BACKGROUND

The available prognostic scoring systems for acute pancreatitis have limitations that restrict their clinical value.

AIMS

To develop a decision model based on classification and regression tree (CART) analysis for the prediction of severe acute pancreatitis (SAP).

METHODS

A total of 420 patients with acute pancreatitis were enrolled. Study participants were randomly assigned to the training sample and test sample in a 2:1 ratio. First, univariate analysis and logistic regression analysis were used to identify predictors associated with SAP in the training sample. Then, CART analysis was carried out to develop a simple tree model for the prediction of SAP. A receiver operating characteristic (ROC) curve was constructed in order to assess the performance of the model. The prediction model was then applied to the test sample.

RESULTS

Four variables (systemic inflammatory response syndrome [SIRS], pleural effusion, serum calcium, and blood urea nitrogen [BUN]) were identified as important predictors of SAP by logistic regression analysis. A tree model (which consisted of pleural effusion, serum calcium, and BUN) that was developed by CART analysis was able to early identify among cohorts at high (79.03%) and low (7.80%) risk of developing SAP. The area under the ROC curve of the tree model was higher than that of the APACHE II score (0.84 vs. 0.68; P < 0.001). The predicted accuracy of the tree model was validated in the test sample with an area under the ROC curve of 0.86.

CONCLUSIONS

A decision tree model that consists of pleural effusion, serum calcium, and BUN may be useful for the prediction of SAP.

Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis

OBJECTIVE

The purpose of this study was to compare the modified CT severity index (MCTSI) with the CT severity index (CTSI) regarding assessment of severity parameters in acute pancreatitis (AP). Both CT indexes were also compared with the Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) index.

MATERIALS AND METHODS

Of 397 consecutive cases of AP, 196 (49%) patients underwent contrast-enhanced CT (n = 175) or MRI (n = 21) within 1 week of onset of symptoms. Two radiologists independently scored both CT indexes. Severity parameters included mortality, organ failure, pancreatic infection, admission to and length of ICU stay, length of hospital stay, need for intervention, and clinical severity of pancreatitis. Discrimination analysis and kappa statistics were performed.

RESULTS

Although for both CT indexes a significant relationship was observed between the score and each severity parameter (p < 0.0001), no significant differences were seen between the CT indexes. Compared with the APACHE II index, both CT indexes more accurately correlated with the need for intervention (CTSI, p = 0.006; MCTSI, p = 0.01) and pancreatic infection (CTSI, p = 0.04; MCTSI, p = 0.06) and more accurately diagnosed clinically severe disease (area under the curve, 0.87; 95% CI, 0.82-0.92). Interobserver agreement was excellent for both indexes: for CTSI, 0.85 (95% CI, 0.80-0.90) and for MCTSI, 0.90 (95% CI, 0.85-0.95).

CONCLUSION

No significant differences were noted between the CTSI and the MCTSI in evaluating the severity of AP. Compared with APACHE II, both CT indexes more accurately diagnose clinically severe disease and better correlate with the need for intervention and pancreatic infection.

Interventional radiology for necrotizing pancreatitis

Necrotic pancreatitis is a complex clinical entity that requires collaboration of care from surgeons, gastroenterologists, and interventional radiologists. CT scans play a pivotal role in the diagnosis of pancreatic necrosis, while image-guided percutaneous pancreatic drainage is a safe and effective treatment method in certain cases. The diagnostic criteria for pancreatic necrosis, indications for pancreatic drainage, technique, and efficacy are discussed in this article.

Biliary, pancreatic, and hepatic imaging for the general surgeon

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Severe acute pancreatitis requiring drainage therapy: findings on computed tomography as predictor of patient outcome

BACKGROUND/AIMS

To evaluate whether morphologic features on computed tomography (CT) correlate with outcome of patients with severe acute pancreatitis (SAP).

METHODS

80 patients with SAP requiring percutaneous drainage therapy were retrospectively analyzed. Twelve CT features beyond the CT severity index (CTSI) were studied. Endpoints for patient outcome were patient death, length of hospital and ICU stay. The twelve features and the CTSI score were correlated with mortality using Kaplan-Meier estimator and correlated with length of hospital and ICU stay using the χ(2) test. A p value ≤0.05 was considered statistically significant.

RESULTS

Two CT features exhibited a significant correlation with mortality: (1) the number of parts of pancreas (head, corpus, tail) that exhibited areas of necrosis and (2) the presence of distant fluid collections (posterior pararenal space and/or paracolic gutter). Mortality was 42% (21 of 50 patients) and 20% (6 of 30 patients) if two/all three parts or none/one part of the pancreas exhibited necrosis, respectively. Mortality was 46% (18 of 39 patients) and 22% (9 of 41 patients) if distant fluid collections were present or absent, respectively. All other imaging features including the CTSI showed no significant correlation with patient outcome.

CONCLUSION

We identified two morphologic features on CT that might be helpful to predict prognosis of patients suffering from SAP. and IAP.

Discrepancy between the extent of pancreatic necrosis and multiple organ failure score in severe acute pancreatitis

BACKGROUND

Whether pancreatic necrosis is a prerequisite for the development of multiorgan failure (MOF) in severe acute pancreatitis (AP) is not clear and has implications for the rational design of translational therapies. This study was designed to investigate the magnitude of any association between MOF and radiologically evident pancreatic or extrapancreatic complications of AP.

METHODS

Data regarding 276 patients with AP were analyzed retrospectively with regard to clinical presentation, MOF severity, computerized tomography (CT) evidence of pancreatic necrosis, and modified CT severity index (MCTSI).

RESULTS

Agreement between the presence of necrosis and MOF status was seen in 160 of 276 patient episodes (58%; 95% confidence intervals (CI), 52.1-63.8%). In 116 of 276 episodes, the MCTSI and MOF scores disagreed (42%; 95% CI, 36.2-47.9%). CT evidence of pancreatic necrosis was present in 21 of 104 (20.2%) patients without any evidence of MOF, and there was no evidence of necrosis on CT scan in 95 of 176 (54%) patients with MOF. Full-factorial univariate analysis suggested that extrapancreatic complications seen on CT, in particular intra-abdominal fluid collections (effect size = 0.02; P = 0.016) and abnormal liver enhancement (effect size = 0.035; P = 0.031) were associated with severity of MOF, and exerted an even greater effect when they occurred synchronously.

CONCLUSIONS

The discrepancy between the presence of necrosis and the occurrence of MOF favors association but not cause in AP. A complex, systems-based, pleiotropic inflammatory network with a common root, in which the extent of pancreatic necrosis influences the severity of MOF in certain individuals and MOF exacerbates the development of pancreatic necrosis in others, seems more likely.

Acute pancreatitis: the role of imaging in diagnosis and management

Acute pancreatitis is one of the more commonly encountered aetiologies in the emergency setting and its incidence is rising. Presentations range from a mild-self limiting condition which usually responds to conservative management to one with significant morbidity and mortality in its most severe forms. While clinical criteria are necessary to make the initial diagnosis, contrast-enhanced CT is the mainstay of imaging and has a vital role in assessing the extent and evolution of the disease and its associated complications. The purpose of this article is to summarise the natural course of acute severe pancreatitis, clarify confusing nomenclature, demonstrate the morphological stages in conjunction with radiological scoring systems and illustrate the complications. We will review and illustrate the increasing and significant role interventional radiology has in the management of these patients, which are often life-saving and surgery-sparing.

Acute pancreatitis: imaging utilization practices in an urban teaching hospital--analysis of trends with assessment of independent predictors in correlation with patient outcomes

PURPOSE

To evaluate imaging utilization trends in patients with acute pancreatitis (AP) and to assess independent predictors of radiology usage in relation to patient outcomes.

MATERIALS AND METHODS

Institutional review board approval was obtained for this HIPAA-compliant study; written informed consent was waived. AP-related radiologic studies in 252 patients admitted for AP between June 2005 and December 2007 were collected during and for a 1-year period after hospitalization. Clinical data were collected from patients' medical records, while imaging data were obtained from the radiology information system. Linear regression models were used to investigate predictors and time trends of imaging utilization, after adjustment for confounders. Patient outcomes, measured by using mortality, intensive care unit admission, need for surgical intervention, organ failure, and persistent systemic inflammatory response syndrome, were evaluated by using logistic regression.

RESULTS

Mean utilization was 9.9 radiologic studies per patient (95% confidence interval: 7.5, 12.3), with relative value unit (RVU) of 7.8 (95% confidence interval: 6.3, 9.4). Utilization was highest on day 0, declining rapidly by day 4; 53% of imaging occurred during initial hospitalization. Chest radiography (38%) and abdominal computed tomography (CT) (17%) were the most commonly performed studies. Patients with longer hospital stay (P = .001), higher Acute Physiology and Chronic Health Evaluation II score (P = .0012), higher pain levels (P = .003), drug-induced AP (P = .002), and prior episodes of AP (P < .001) underwent significantly more radiologic studies. After adjustment for confounders, a 2.5-fold increase in the use of high-cost (CT and magnetic resonance imaging) examinations and a 1.4-fold increase in RVUs per case-mix-adjusted admissions (P < .05) were observed during the 2.5-year study period. This increased use was not associated with improvement in patient outcomes.

CONCLUSION

AP severity explained substantial variation in imaging utilization. After case-mix adjustment for severity and other patient level factors, there was still increasing use over the course of time without notable improvement in patient outcomes.

Practical guidelines for acute pancreatitis

INTRODUCTION

The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis.

STATEMENTS

Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48-72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B).

CONCLUSIONS

The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.

Imaging of acute pancreatitis: prognostic value of computed tomographic findings

Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey up to 25%, 52%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis increase morbidity and mortality to a lesser degree.We review the computed tomographic findings of complications associated with acute pancreatitis with emphasis on their prognostic significance and impact on clinical management.

Nosocomial mortality and early prediction of patients with severe acute pancreatitis

BACKGROUND AND AIMS

The aim of this study is to analyze factors (especially serum total cholesterol) that can enable early prediction of in-hospital mortality of patients with severe acute pancreatitis (SAP).

METHODS

Predictive factors (especially serum total cholesterol) for in-hospital mortality were evaluated retrospectively from the clinical data obtained from 338 SAP patients in our hospital from January 1999 to January 2008, who underwent intensive care, blood routine, blood biochemical tests and even computed tomography at the time of admission.

RESULTS

This analysis revealed that within 24 h after admission, serum total cholesterol (TC) was a mortality-reduced factor when it is between 4.37 mmol/L and 5.23 mmol/L (P < 0.05). Evaluated TC was accompanied by decreased C-reactive protein (CRP). CRP > 170 mg/L and albumin (ALB) < 30 g/L increased the fatal outcome (P < 0.05). Low albumin was a stronger predictor than CRP.

CONCLUSIONS

Within 24 h after admission, moderate elevation of TC level seemed to increase the resistance to inflammation and hence improved the survival rate in patients with SAP, and reduced the in-hospital mortality. Inflammatory reaction (with or without infection), hypoalbuminemia and TC were prognostic factors for in-hospital mortality; both high levels of CRP and low ALB levels were associated with in-hospital mortality in patients with SAP.

APCAP--activated protein C in acute pancreatitis: a double-blind randomized human pilot trial

Introduction

Previous human studies have shown low activity of protein C (APC) in severe acute pancreatitis (SAP). This, together with the findings in animal models, suggests that activated protein C (APC) may protect against pancreatic injury and ameliorate the disease. We, therefore, evaluated its effect on multiple organ dysfunction (MOD) measured by the SOFA (Sequential Organ Failure Assessment) and on organ-failure-free days, and the safety of APC in SAP.

Methods

A prospective double blind randomized pilot study was use. The study occurred in one university hospital tertiary intensive care unit (ICU) with eight beds. The patients were chosen according to the following inclusion criteria: 1) Those admitted to the hospital < 96 h from the onset of pain, 2) Those who had a three-fold increase in serum amylase over normal upper range or/and in whom computed tomography (CT) verification of SAP was noted, 3) Those who had one or more organ dysfunction (OD), and 4) Those in whom less than 48 hours had passed since their first OD. Of a total of 215 adult patients with SAP screened between June 2003 and August 2007, 158 fulfilled the study inclusion criteria. After exclusions 32 patients were randomized to the study. The intervention consisted of APC (N = 16) administered intravenously for 96 hours with a dose of 24 μg/kg/hour or placebo (N = 16) with a similar infusion rate. The sample size for the study was calculated according to the primary end-point: the change in SOFA during study drug infusion (Days 0 and 5). Comparisons between the study groups were performed using patient-related changes and calculation of difference in means (DIM, 95% CIs) and regarding categorical variables with Fisher's exact test. For all comparisons P < 0.05 was considered significant.

Results

No serious bleeding was detected clinically or by CT scans in either group. No significant difference in SOFA score change between the APC and placebo groups was found (difference in means (DIM) +2.3, 95% CI -0.7 to +5.3). Treatment with APC was associated with an increase in serum levels of both total and conjugated bilirubin. No differences in ventilator-free days, in renal replacement therapy-free days, in vasopressor-free days, or in days alive outside the hospital were detected.

Conclusions

No serious bleeding or differences in the evolution of MOD were detected between APC and the placebo. Instead we found an increase in serum bilirubin in the APC group compared to the placebo group in patients with SAP.

Trial registration

ClinicalTrials.gov NCT01017107.

Contrast-enhanced ultrasound in the staging of acute pancreatitis

OBJECTIVE

To determine the diagnostic value of contrast-enhanced ultrasound (CEUS) in the assessment of acute pancreatitis, with computed tomography (CT) as the reference standard.

METHODS

Fifty consecutive patients (mean age 58.4 years; range 23-86 years) with acute pancreatitis underwent prospectively both CT and ultrasonography, including CEUS, within a 24-h interval. Pancreatic vascularisation was evaluated with CEUS after injection of a second-generation US contrast-enhancing agent. Acute pancreatitis severity was graded according to the Balthazar index. The results were compared with CT severity index and clinical outcome by using Spearman's correlation coefficient.

RESULTS

A significant correlation between CT and CEUS was found for the CT severity index (r = 0.926), extent of necrosis (r = 0.893) and Balthazar grade (r = 0.884). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting severe acute pancreatitis based on CT findings (severity index greater than 3 and/or presence of necrosis) were respectively 91%, 100%, 100% and 83%. A significant correlation between CEUS severity index and clinical variables was found: Ranson score (r = 0.442), C-reactive protein (CRP) levels 48 h after admission (r = 0.385) and length of hospital stay (r = 0.362).

CONCLUSION

CEUS is comparable to CT in detecting pancreatic necrosis as well as predicting its clinical course. Therefore, when CT is contraindicated CEUS may be a valid alternative.

[Evaluation of severity in acute pancreatitis]

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.