Acute pancreatitis: radiologic scores in predicting severity and outcome

D-dimer as a Marker of Severity and Prognosis in Acute Pancreatitis

Background and Objectives

Acute pancreatitis (AP) scores need a battery of tests that are not helpful at an early stage. Can a single test predict Complicated Acute Pancreatitis (CAP) which includes moderate and severe AP, local complications, and need for intensive care unit (ICU).

Methodology

30 patients of AP. D-dimer, C-reactive protein levels done within 3 days of AP onset. APACHE II, Ranson's score, CT severity index were done. Inhospital disease course for development of organ failure and need for ICU care was followed daily.

Results

D-dimer in CAP was 2732 ng/L (MAP 567 ng/L), in abnormal computed tomography (CT) was 1916 ng/L (normal CT 363 ng/L), and in organ failure was 4776 ng/L (776.5 ng/L absent organ failure). D-dimer increases as the severity of organ failure increases (P = 0.04). D-dimer in ICU patients was significantly elevated (P = 0.021). D-dimer correlates with APACHE II score well, with an increase in predictive mortality rate (P = 0.01). On receiver operator characteristics, D-dimer >933.5 ng/L predicts CAP, >827.5 ng/L predicts positive CT findings (local complications), and >1060.5 ng/L predicts the development of organ failure.

Conclusion

Coagulopathy and microthrombi play a significant role in early pathogenesis. D-dimer test acts at the level of this core pathogenesis, even before the complications set in. D-dimer within 72 h of AP correlates well with the CT findings after 72 h. This is the first study that correlates D-dimer levels with CT scores, ICU requirement. D-dimer can guide primary care physicians in selecting AP patients for referral to a higher center in a resource-limited setting.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis

PURPOSE

It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2 weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC).

MATERIALS AND METHODS

This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7 days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups.

RESULTS

One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031).

CONCLUSION

Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

Role of Extrapancreatic Necrosis Volume in Assessing the Severity and Predicting the Outcomes of Severe Acute Pancreatitis

Objective

To observe the relationship between the extrapancreatic necrosis volume and outcomes in patients with severe acute pancreatitis (SAP).

Methods

We retrospectively analyzed 125 patients with SAP admitted to Severe Acute Pancreatitis Treatment Center of Guizhou Province from August 2013 to August 2018. All patients had extrapancreatic necrosis. The general clinical data of patients, C-reactive protein (CRP) value within 72 hours of onset, Ranson score, organ failure within 3 days after onset, complications, outcomes, CT severity index (CTSI), extrapancreatic necrosis volume and other information were collected. The correlation between extrapancreatic necrosis volume and hospitalization time, ICU stay, hospitalization cost, and CRP value was analyzed. The incidence of complications was obtained from the electronic medical record system.

Results

The mean extrapancreatic necrosis volume was 680 ± 473 mL. The median length of hospital stay was 18.2 (3–76) days, and the ICU stay was 13.5 (3–66) days. The extrapancreatic necrosis volume was positively correlated with hospitalization time, ICU stay time, cost of hospitalization and CRP (P < 0.05). The extrapancreatic necrosis volume in organ failure group was significantly higher than that in non-organ failure group (P < 0.05). The extrapancreatic necrosis volume in patients with death was also higher than that in survival (P < 0.05). With the increase of extrapancreatic necrosis volume, the incidence of complications increased significantly. On the basis of extrapancreatic necrosis volume, the ROC curves yielded an AUC of 0.92 (95% CI: 0.83, 0.99) in predicting the mortality, which was higher than Ranson score (0.90, 95% CI 0.82–0.96) and CTSI (0.85, 0 95% CI 0.77–0.91).

Conclusion

With the increase of extrapancreatic necrosis volume, the incidence of complications increased significantly. The extrapancreatic necrosis volume has the potential to be used as a valuable tool to predict the poor outcome of acute pancreatitis.

Extrapancreatic necrosis volume: A new tool in acute pancreatitis severity assessment?

BACKGROUND

Many scores have been suggested to assess the severity of acute pancreatitis upon onset. The extrapancreatic necrosis volume is a novel, promising score that appears to be superior to other scores investigated so far.

AIM

To evaluate the discriminatory power of extrapancreatic necrosis volume to identify severe cases of acute pancreatitis.

METHODS

A total of 123 patients diagnosed with acute pancreatitis at Institute of Gastroenterology and Hepatology, St Spiridon Hospital between January 1, 2017 and December 31, 2019 were analyzed retrospectively. Pancreatitis was classified according to the revised Atlanta classification (rAC) as mild, moderate, or severe. Severity was also evaluated by computed tomography and classified according to the computed tomography severity index (CTSI) and the modified CTSI (mCTSI). The results were compared with the extrapancreatic volume necrosis to establish the sensitivity and specificity of each method.

RESULTS

The CTSI and mCTSI imaging scores and the extrapancreatic necrosis volume were highly correlated with the severity of pancreatitis estimated by the rAC (r = 0.926, P < 0.001 and r = 0.950, P < 0.001; r = 0.784, P < 0.001, respectively). The correlation of C-reactive protein with severity was positive but not as strong, and was not significant (r = 0.133, P = 0.154). The best predictor for the assessment of severe pancreatitis was the extrapancreatic necrosis volume [area under the curve (AUC) = 0.993; 95% confidence interval (CI): 0.981-1.005], with a 99.5% sensitivity and 99.0% specificity at a cutoff value of 167 mL, followed by the mCTSI 2007 score (AUC = 0.972; 95%CI: 0.946-0.999), with a 98.0% sensitivity and 96.5% specificity, and the CTSI 1990 score (AUC = 0.969; 95%CI: 0.941-0.998), with a 97.0% sensitivity and 95.0% specificity.

CONCLUSION

Radiological severity scores correlate strongly and positively with disease activity. Extrapancreatic necrosis volume shows the best diagnostic accuracy for severe cases.

Development and validation of a computed tomography index for assessing outcomes in patients with acute pancreatitis: "SMART-CT" index

PURPOSE

The existing CT indices do not allow quantitative prediction of clinical outcomes in acute pancreatitis (AP). The aim of this study was to develop and validate a revised CT index using a nomogram-based approach.

METHODS

This retrospective study comprised consecutive patients with AP who underwent contrast-enhanced CT between June 2017 and March 2019. 123 CT scans were randomly divided into training (n = 103) and validation groups (n = 20). Two radiologists analyzed CT scans for findings described in modified CT severity index and additional exploratory items (13 items). Seven items (pancreatic necrosis, number of collections, size of collections, ascites, pleural effusion, celiac artery involvement, and liver steatosis) found to be statistically significant were used for development of index. Synthetic minority oversampling technique (SMOTE) was employed to balance representation of minority classes and hence this index was named "SMOTE Application for Reading CT in AcuTe Pancreatitis (SMART-CT index)". Binomial logistic regression was used for development of prediction algorithm. Nomograms were then created and validated for each outcome.

RESULTS

The new CT index had area under the curve (AUC) of 0.79 [95% CI 0.65-0.93], 0.66 (95% CI 0.54-0.77), 0.75 (95% CI 0.65-0.85), 0.83 (95% CI 0.69-0.96), 0.70 (95% CI 0.60-0.81), and 0.64 (95% CI 0.53-0.75) for mortality, intensive care unit (ICU) stay, length of hospitalization, length of ICU stay, number of admissions, and severity, respectively. The AUC of validation cohort was comparable to the training cohort.

CONCLUSION

The novel nomogram-based index predicts occurrence of clinical outcome with moderate accuracy.

Extra Pancreatic Necrotic Volume: Can It Prognosticate Acute Necrotising Pancreatitis— A Prospective Study

Background Acute necrotizing pancreatitis (ANP) is associated with higher mortality and morbidity. We need a method which is accurate in predicting the prognosis, and when applied early in the disease process, can help in closer monitoring and early initiation of treatment for at-risk patients.

Objectives The aim of this prospective study was to assess the extra pancreatic necrosis (EPN) volume in patients with ANP and compare it with outcome variables such as organ failure, death and need for intervention as well as to compare the predictive power of EPN volume with modified CT severity index (CTSI).

Materials and Methods The study had 48 patients with clinical diagnosis of acute pancreatitis, who underwent Contrast enhanced CT (CECT) between 3–6 days of onset. In all these patients, EPN volume (in cubic centimetre) and modified CTSI score were calculated and compared with the patient outcome parameters such as duration of hospital/ICU stay, need for percutaneous/surgical intervention, evidence of infection and organ failure. The results were compared with assess the predictive power of EPN volume.

Statistical analysis The analysis was done in SPSS version 16.0 for windows. Pearson Correlation was used to assess the significant relationship between selected objective variables.

Results EPN volume (>/= to 360 cc) had a statistically significant correlation with outcome parameters as well as in predicting overall organ failure. In our study, Modified CTSI had no significant correlation with the above mentioned factors.

Conclusions The volume of EPN calculated between 3rd and 6th day of onset of symptoms showed a significant correlation with the outcome in patients with ANP.

Site and size of extrapancreatic necrosis are associated with clinical outcomes in patients with acute necrotizing pancreatitis

BACKGROUND

The site and size of extrapancreatic necrosis (EPN) as assessed on computed tomography may influence the severity of acute necrotizing pancreatitis (ANP). The objective of the study was to evaluate the impact of site and size of EPN on the clinical outcomes in patients with acute necrotizing pancreatitis (ANP).

METHOD AND MATERIALS

This retrospective study comprised of consecutive patients with ANP who were admitted between January 2017 and March 2019. Patients in whom the initial contrast enhanced CT showed EPN were eligible for inclusion. The site, volume and maximum dimension of EPN were recorded. The severity of AP and modified CT severity index (MCTSI) was calculated. Clinical outcomes were recorded.

RESULTS

A total of 119 patients (mean age, 37.56 years, 91 males) were included. There was a significant association between the location of EPN and the outcome parameters. The left posterior pararenal collections were significantly associated with mortality (P = 0.041), left paracolic gutter collections with the length of hospitalisation (LOH) (P = 0.014), and right paracolic gutter and mesenteric collections with the intensive care unit (ICU) stay (P = 0.024, and P = 0.021, respectively). There was a significant correlation between the volume and the maximum dimension of collection with LOH and ICU stay. The area under the receiver operating characteristic curve for volume, maximum dimension and MCTSI for predicting death was 0.724 (95% CI, 0.612-0.837), 0.644 (95% CI, 0.516-0.772) and 0.574 (95% CI, 0.452-0.696), respectively.

CONCLUSION

The site and size of EPN provide reliable and objective information for assessing clinical outcomes in patients with ANP.

Radiology of acute pancreatitis today: the Atlanta classification and the current role of imaging in its diagnosis and treatment

Acute pancreatitis is common and requires multidisciplinary management. The revised Atlanta classification, published in 2012, defines the terminology necessary to enable specialists from different backgrounds to discuss the morphological and clinical types of acute pancreatitis. Radiologists' role depends fundamentally on computed tomography (CT), which makes it possible to classify the morphology of this disease and to predict its clinical severity by applying imaging severity indices. Furthermore, CT- or ultrasound-guided drainage is, together with endoscopy, the current technique of choice in the initial approach to collections that appear as a complication. This paper aims to disseminate the concepts coined in the revised Atlanta classification and to describe the current role of radiologists in the diagnosis and treatment of acute pancreatitis.

Radial EUS Examination Can be Helpful in Predicting the Severity of Acute Biliary Pancreatitis

We investigated the utility of noncontrast enhanced endosonography (EUS) in predicting the severity of acute pancreatitis (AP) during the first 72 to 96 h of admission.In total, 187 patients with acute biliary pancreatitis were included. The patients were classified into 2 groups as having severe and mild AP according to the Modified Glasgow scoring and computerized tomography severity index (SI). The 158 cases with mild and 29 cases with severe AP had a similar age and sex distribution.Although none of the cases with mild AP developed morbidity and death, of the cases with severe AP, 16 developed serious morbidities and 5 died. On EUS examination, we looked for parenchymal findings, peripancreatic inflammatory signs, free or loculated fluid collections, and abnormalities of the common bile duct and the pancreatic channel. Statistical analysis indicated a significant relationship between the severity of AP with diffuse parenchymal edema, periparenchymal plastering, and/or diffuse retroperitoneal free fluid accumulation, and peri-pancreatic edema. We also defined an EUSSI and found that the EUSSI had sensitivity of 89.7%, specificity of 84.2%, positive predictivity value (PPV) of 88.9%, negative predictivity value (NPV) of 91.2%, and an accuracy of 87.9% in the differentiation of mild and severe AP. We found that the EUSSI had an accuracy of 72.4%, sensitivity of 75.4%, specificity of 65.1%, PPV of 69.3%, and NPV of 73.1% for determining mortality.Our data suggest that EUS allowed us to accurately predict the severity and mortality in nearly 90% of cases with AP.

Mortality indicators and risk factors for intra-abdominal hypertension in severe acute pancreatitis

This study assessed the risk factors associated with mortality and the development of intra-abdominal hypertension (IAH) in patients with severe acute pancreatitis (SAP). To identify significant risk factors, we assessed the following variables in 102 patients with SAP: age, gender, etiology, serum amylase level, white blood cell (WBC) count, serum calcium level, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, computed tomography severity index (CTSI) score, pancreatic necrosis, surgical interventions, and multiple organ dysfunction syndrome (MODS). Statistically significant differences were identified using the Student t test and the χ (2) test. Independent risk factors for survival were analyzed by Cox proportional hazards regression. The following variables were significantly related to both mortality and IAH: WBC count, serum calcium level, serum amylase level, APACHE-II score, CTSI score, pancreatic necrosis, pancreatic necrosis >50%, and MODS. However, it was found that surgical intervention had no significant association with mortality. MODS and pancreatic necrosis >50% were found to be independent risk factors for survival in patients with SAP. Mortality and IAH from SAP were significantly related to WBC count, serum calcium level, serum amylase level, APACHE-II score, CTSI score, pancreatic necrosis, and MODS. However, Surgical intervention did not result in higher mortality. Moreover, MODS and pancreatic necrosis >50% predicted a worse prognosis in SAP patients.

Acute pancreatitis gravity predictive factors: which and when to use them?

INTRODUCTION

Acute pancreatitis has as its main causes lithiasic biliary disease and alcohol abuse. Most of the time, the disease shows a self-limiting course, with a rapid recovery, only with supportive treatment. However, in a significant percentage of cases, it runs with important local and systemic complications associated with high mortality rates.

AIM

To present the current state of the use of these prognostic factors (predictive scores) of gravity, as the time of application, complexity and specificity.

METHOD

A non-systematic literature review through 28 papers, with emphasis on 13 articles published in indexed journals between 2008 and 2013 using Lilacs, Medline, Pubmed.

RESULTS

Several clinical, laboratory analysis, molecular and image variables can predict the development of severe acute pancreatitis. Some of them by themselves can be determinant to the progression of the disease to a more severe form, such as obesity, hematocrit, age and smoking. Hematocrit with a value lower than 44% and serum urea lower than 20 mg/dl, both at admission, appear as risk factors for pancreatic necrosis. But the PCR differentiates mild cases of serious ones in the first 24 h. Multifactorial scores measured on admission and during the first 48 h of hospitalization have been used in intensive care units, being the most ones used: Ranson, Apache II, Glasgow, Iget and Saps II.

CONCLUSION

Acute pancreatitis is a disease in which several prognostic factors are employed being useful in predicting mortality and on the development of the severe form. It is suggested that the association of a multifactorial score, especially the Saps II associated with Iget, may increase the prognosis accuracy. However, the professional's preferences, the experience on the service as well as the available tools, are factors that have determined the choice of the most suitable predictive score.

Correlation analysis of computed tomography imaging score with the presence of acute kidney injury in severe acute pancreatitis

OBJECTIVES

The aim of the study is to investigate the CT imaging findings of severe acute pancreatitis (SAP) complicated with acute kidney injury (AKI) and evaluate the correlation between the CT imaging score and the presence of AKI in SAP.

MATERIALS AND METHODS

Contrast-enhanced CT scanning was performed for all 145 patients. Related CT indices such as Balthazar CT grading, CTSI and EPIC scores were calculated. Clinical data, including APACHE II, Ranson scores, serum creatinine levels, urine output, and mortality, were then collected and compared with CT indices.

RESULTS

The EPIC score showed a larger area under the receiver operating characteristic curve than either of the CTSI or Balthazar score. However, the change of APACHE II score, but not EPIC score, was significantly associated with the prognosis of AKI and eventual clinical outcome. In addition, the CT manifestation of fluid encapsulation was a good predictor of recovery from AKI.

CONCLUSIONS

Among the CT indices, the EPIC score, which possessed a good correlation with both APACHE II and Ranson scores, provided a better prediction of AKI in SAP patients than CTSI and Balthazar scores. Encapsulation of inflammatory exudates might be used in the future as imaging-based prognostic criteria of recovering from AKI in patients with SAP.

Acute Pancreatitis: Extrapancreatic Necrosis Volume as Early Predictor of Severity

PURPOSE

To determine the volume of extrapancreatic necrosis that predicts severe acute pancreatitis and to assess the reliability of this threshold in predicting severe acute pancreatitis compared with current scoring systems and C-reactive protein (CRP) levels.

MATERIALS AND METHODS

This institutional review board-approved, HIPAA-compliant retrospective study included patients with acute pancreatitis who were examined with computed tomography (CT) 2-6 days after disease onset. Extrapancreatic necrosis volume, Balthazar score, and CT severity index (CTSI) were calculated. CRP levels 48 hours after the onset of symptoms were reviewed. Outcome parameters included organ failure, infection, need for surgery or percutaneous intervention, duration of hospitalization, and/or death. Receiver operating characteristic (ROC) curves were constructed to determine the optimal threshold for predicting clinical outcomes. Pairwise comparisons of areas under ROC curves (AUCs) from the different grading systems were performed. Interobserver and intraobserver agreement in the grading of extrapancreatic necrosis was assessed by using κ statistics.

RESULTS

In 264 patients, significant relationships were found between extrapancreatic necrosis volume and organ failure, infection, duration of hospitalization, need for intervention, and death (P < .001 for all). The optimal threshold for predicting severe acute pancreatitis was 100 mL. Sensitivity and specificity were 95% (19 of 20) and 83% (142 of 172), respectively, for predicting organ failure (vs 100% [20 of 20] and 46% [79 of 172] for the Balthazar score and 25% [five of 20] and 95% [163 of 172] for the CTSI). The extrapancreatic necrosis AUC was the highest for all systems. Interobserver and intraobserver agreement based on the 100-mL threshold was considered to be excellent.

CONCLUSION

A simple grading system based on an objective criterion such as a threshold of 100 mL of extrapancreatic necrosis provides more reliable information for predicting acute pancreatitis outcomes than do the current scoring systems.

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.

Persistent salmonellosis causes pancreatitis in a murine model of infection

Pancreatitis, a known risk factor for the development of pancreatic ductal adenocarcinoma, is a serious, widespread medical condition usually caused by alcohol abuse or gallstone-mediated ductal obstruction. However, many cases of pancreatitis are of an unknown etiology. Pancreatitis has been linked to bacterial infection, but causality has yet to be established. Here, we found that persistent infection of mice with the bacterial pathogen Salmonella enterica serovar Typhimurium (S. Typhimurium) was sufficient to induce pancreatitis reminiscent of the human disease. Specifically, we found that pancreatitis induced by persistent S. Typhimurium infection was characterized by a loss of pancreatic acinar cells, acinar-to-ductal metaplasia, fibrosis and accumulation of inflammatory cells, including CD11b+ F4/80+, CD11b+ Ly6Cint Ly6G+ and CD11b+ Ly6Chi Ly6G- cells. Furthermore, we found that S. Typhimurium colonized and persisted in the pancreas, associated with pancreatic acinar cells in vivo, and could invade cultured pancreatic acinar cells in vitro. Thus, persistent infection of mice with S. Typhimurium may serve as a useful model for the study of pancreatitis as it relates to bacterial infection. Increased knowledge of how pathogenic bacteria can cause pancreatitis will provide a more integrated picture of the etiology of the disease and could lead to the development of new therapeutic approaches for treatment and prevention of pancreatitis and pancreatic ductal adenocarcinoma.

An evidence-based proposal for predicting organ failure in severe acute pancreatitis

OBJECTIVES

Early, efficient, and accurate evaluation for organ failure is an important step for improving outcome in severe acute pancreatitis (SAP). We aim to develop a method that can early, efficiently, and accurately evaluate the in-hospital organ failure in patients with SAP.

METHODS

Using multivariate logistic regression analysis, the associative factors for in-hospital organ failure were evaluated retrospectively from conventional data obtained from 393 patients with SAP from 2000 to 2012. In classification and regression tree analysis, a new clinical scoring system was developed for the evaluation of in-hospital organ failure in SAP. We also compared the accuracy of our new scoring system with multiple organ dysfunction score and Acute Physiology and Chronic Health Examination II score by the receiver operating characteristic curve.

RESULTS

Laboratory results revealed serum calcium level greater than or equal to 1.84 mmol/L, serum creatinine level greater than or equal to 110 µmol/L, age greater than or equal to 72 years, activated partial thromboplastin time less than or equal to 30.95 seconds, and Balthazar computed tomography score greater than or equal to 7 (CCAAB) score system, each contributed 1 point for the prediction of organ failure. The area under the curve of the CCAAB score system was similar to multiple organ dysfunction scores and Acute Physiology and Chronic Health Examination II scores.

CONCLUSIONS

The new scoring system CCAAB is an efficient and accurate method for the early evaluation of patients with SAP for in-hospital organ failure.

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.

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.

Prognostic value of increased B type natriuretic peptide in cases with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a systemic disease with a rising incidence. Cardiac dysfunction may occur as an early complication of AP. B type natriuretic factor (BNP) is a diagnostic and prognostic indicator of cardiac disorders. Therefore, in this study we aimed to assess the relationship between serum BNP concentrations and severity of AP.

METHODS

Patients with AP who were admitted to gastroenterology clinic of our center, were included in this study. BNP measurements were performed twice, once on admission to the hospital and another after clinical and laboratory remission of the disease. All patients underwent echocardiography, abdominal ultrasonography and/or computed tomography chest X-ray and routine biochemical assays. Disease severity was determined by Ranson, Balthazar and Glasgow scoring systems.

RESULTS

A total of 55 patients with AP (33 male, 60%) were enrolled in the study. Causes of AP were biliary in 32 patients (58%), alcoholic in 10 (18%), idiopathic in 8 (15%), hyperlipidemic in 4 (7%) and ERCP related in one patient (2%), respectively. Serum BNP levels in first 2 days of admission and after the clinical and laboratory remission of disease were 444 ± 295.9 and 124 ± 109.5 pg/ml, respectively (p<0.001). Increased serum BNP levels were positively correlated with severity of the disease (p<0.001). We could not find a difference between serum BNPe levels of edematous and necrotizing patients (P = 0.683).

CONCLUSION

Increased serum BNP levels might be a plausible indicator of severity of AP during the course of the disease.

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.

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.