Clinical utility of the revised Atlanta classification of acute pancreatitis in a prospective cohort: have all loose ends been tied?

S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

Metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off pancreatic necrosis

Pancreatic fluid collections (PFCs) are one of the local complications of acute pancreatitis and include walled-off pancreatic necrosis (WOPN), which are complex entities with challenging management. The infection of pancreatic necrosis leads to a poorer prognosis, with a growth of the mortality rate up to 30%. The primary strategy for managing PFCs is a minimally invasive step-up approach, with endosonography-guided transmural drainage and debridement as the preferred and less invasive method. Percutaneous drainage (PCD) can be the technique of choice when endoscopic drainage is not feasible, for example for early PFCs without a mature wall or for the anatomic location and extension to the paracolic gutter of the collection. As PCD alone may be ineffective, especially when a great amount of necrosis is present, a percutaneous endoscopic necrosectomy (PEN) has been proposed, showing interesting results. The technique consists of the placement of an esophageal fully or partially covered self-expandable metal stent (SEMS) percutaneously into the collection and a direct debridement can be performed using a flexible endoscope through the SEMS. In this review, we will discuss about the role of metal stent and PEN for the management of complex walled-off pancreatic necrosis.

Remission of organ failure in patients with predicted severe acute pancreatitis treated by somatostation, octreotide and cyclooxygenase-2 inhibitors

BACKGROUND

/Objectives: Persistent organ failure (OF) in severe acute pancreatitis (SAP) is caused by activation of cytokine cascades, resulting in inflammatory injury. Anti-inflammation may be helpful in OF remission in early SAP. To assess the efficacy of anti-inflammatory regimens for OF prevention and remission in patients with predicted SAP and display clinical doctors' acceptance of these strategies, we conducted this retrospective study in the real world.

METHODS

Clinical data of patients with predicted SAP from 2010 to 2017 were retrospectively reviewed. Cases were divided into conventional support (C), C+ somatostatin/octreotide (C + S/O), and C + S/O + Cyclooxygenase-2-inhibitors (C + S/O + COX-2-I). The occurrence of SAP, OF, changes of proportion for three strategies, length of hospital stay, meperidine injection, and cytokine levels were compared. The constituent ratios of the three schemes over eight years were evaluated.

RESULTS

A total of 580 cases (C = 124, C + S/O = 290, C + S/O + COX-2-I = 166) were included. The occurrences of SAP in the C + S/O (28.3 %) and C + S/O + COX-2-I (18.1 %) groups were significantly lower than that in C group (60.5 %, P < 0.001), mainly by reducing persistent respiratory failure (P < 0.001) and renal failure (P = 0.002). C + S/O and C + S/O + COX-2-I regimens significantly decreased new onset OF and enhanced OF amelioration within 48 h when compared with C treatment (P < 0.001) in patients with OF score <2 and ≥ 2 on admission, respectively. C + S/O and C + S/O + COX-2-I as compared with C group significantly decrease OF occurrences in a multivariate logistic regression analysis (P < 0.05).

CONCLUSIONS

Somatostatin or its analogs and cyclooxygenase-2 inhibitors are promising for OF prevention and remission in patients with predicted SAP. The acceptance of combined strategies in the real world has increased, and the occurrence of SAP has decreased annually.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis

OBJECTIVES

In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989).

METHODS

Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance.

RESULTS

Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032).

CONCLUSION

Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Validation of the Revised Atlanta Criteria in determining the severity of acute pancreatitis

BACKGROUND/AIM

Determining the severity of acute pancreatitis (AP) is crucial for patient management. The aim of our study was to assess the accuracy and limitations of the Revised Atlanta Criteria (RAC) in determining the severity of AP.

MATERIALS AND METHODS

The study was retrospectively conducted on AP patients admitted to the Gastroenterology Department of Sakarya University Faculty of Medicine. The severity, morphology and local complications of AP were evaluated according to the RAC. Laboratory parameters, clinical scores predicting disease severity and Computer Tomography Severity Index scores were assessed.

RESULTS

The study group included 113 patients. Ninety-eight (86.7%) had interstitial edematous, and 15 (13.3%) had necrotizing pancreatitis. AP pancreatitis was mild in 69 (61.1%), moderate in 33 (29.2%), and severe in 11 (9.7%). Compared to the moderate group, patients in the severe group had a higher hematocrit, creatinine, SIRS and BISAP scores at admission and more length of hospital stay, more ICU requirements, and higher mortality rates ( P  < 0.05). Eleven patients had single or multiple persistent organ failure (POF). The mortality rate of patients who developed early POF (n = 6) was higher compared to the group of patients who developed late POF (n = 2) (83.3% and 40%, respectively).

CONCLUSION

Severity assessment using the RAC in patients with AP is consistent with laboratory parameters and scoring systems predicting severity. Severe pancreatitis cases who develop early POF may be classified separately.

Relationship of Arterial Changes in Acute Pancreatitis on CT Angiography with Modified CT Severity Index

Purpose To evaluate the prevalence of arterial changes in patients with acute pancreatitis (AP) on computed tomography angiography (CTA) and determine their association with etiology of AP, presence of necrosis, collections and severity of AP.

Materials and Methods A total of 50 patients (20 women, 30 men; mean age: 43.04 ± 13.98; age range: 18–77 years) with AP underwent contrast-enhanced computed tomography (CECT) scan and CTA of abdomen, which was evaluated for necrosis and fluid collection (s). On CTA, splanchnic arterial structures were assessed for vascular complications. Association between vascular changes and presence of necrosis, fluid collections, etiology of AP and severity of AP (as assessed by modified computed tomography severity index CTSI) was determined.

Results Arterial complications were seen in 28 percent (14/50). The most frequently involved artery was superior pancreaticoduodenal artery (12 percent), followed by splenic artery (8 percent) and right gastric artery (8 percent; Fig. 1). No significant association was seen between arterial changes and gallstone or alcohol-induced AP. Arterial changes showed a significant association with presence of acute necrotizing pancreatitis (ANP), presence of collections and severe AP (CTSI 8–10) (p < 0.05 for each).

Conclusion Arterial changes on CTA are frequently seen in patients of AP having ANP. There is a significant association between arterial changes and presence of necrosis, collections and severe AP.

THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION

BACKGROUND

New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012.

OBJECTIVE

The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices.

METHODS

A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study.

RESULTS

Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification.

CONCLUSION

Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

Recent Advances in Diagnosis and Severity Assessment of Acute Pancreatitis

The incidence and prevalence of acute pancreatitis (AP) is increasing over time. The diagnosis of acute pancreatitis is established by revised Atlanta criteria (2012). Multiple criteria and scoring systems have been used for assessment of severity of AP. Majority of acute pancreatitis cases (80%) are mild, the challenge remains in early diagnosis, severity assessment and treatment of severe AP and its complications. Assessment of severity of AP is important part of management because line of treatment depends on aetiology and severity of acute pancreatitis. In this article a comprehensive review of recent advances in diagnosis and severity assessment of acute pancreatitis has been described.

Reporting of acute pancreatitis by radiologists-time for a systematic change with structured reporting template

Acute pancreatitis has a wide array of imaging presentations. Various classifications have been used in the past to standardize the terminology and reduce confusing and redundant terms. We aim to review the historical and current classifications of acute pancreatitis and propose a new reporting template which can improve communication between various medical teams by use of appropriate terminology and structured radiology template. The standardized reporting template not only conveys the most important imaging findings in a simplified yet comprehensive way but also allows structured data collection for future research and teaching purposes.

Acute pancreatitis: an update on the revised Atlanta classification

Acute pancreatitis (AP) is the most common gastrointestinal disease resulting in hospitalization in the United States with reports of over 270,000 hospitalizations and costs up to 2.6 billion dollars per year. AP is highly variable in disease course and outcome. Established in 1992, the original Atlanta classification system aimed to categorize the wide spectrum of AP by creating consensus-based terminology for AP types, severity, and complications. Though the original system standardized terminology, certain terms and definitions (i.e. pancreatic abscess) were unclear and often misused. The 2012 revised Atlanta classification (RAC) system updated terms, clarified definitions, and incorporated the medical community's improved understanding of the physiology of AP. The resulting RAC effectively defined the morphologic types of pancreatitis, provided a more standardized system for disease severity grading, further classified the local retroperitoneal complications, and established objective measures to describe this highly variable but common disease. This review provides an update on the recent literature evaluating the RAC, discusses both the strengths and shortcomings of the RAC system (including problematic interobserver agreement), and considers improvements for future classification systems.

ESPEN guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20% of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

Plasma D-Dimer Level Is an Early Predictor of Severity of Acute Pancreatitis Based on 2012 Atlanta Classification

Background

Acute pancreatitis (AP) is a common digestive disorder. Its management depends on the severity; therefore, it is essential to stratify AP patients early. D-dimer, a coagulation indicator, appears to be associated with the pathogenesis of AP. The aim of this study was to evaluate D-dimer as an early predictor of the severity of AP.

Material/Methods

This was a single-center retrospective study of 1260 patients diagnosed based on the revised Atlanta classification. Only patients hospitalized within 24 h of onset were included, and 334 patients were enrolled. Blood was collected at admission and 3 times within 48 h of admission. Values at admission and average of the 3 blood samples were evaluated by univariate and multivariate analyses. Furthermore, the area under the receiver-operating characteristic curve (AUC) was used to estimate the validity of the predictor and to define optimal cut-off points for prediction.

Results

We found that 53.3% of the patients had mild AP (MAP), 24.3% had moderately severe AP (MSAP), and 22.4% had severe AP (SAP). D-dimer at admission and the average D-dimer could distinguish MAP patients from MSAP and SAP patients, with cut-off values of 3.355 mg/L and 4.868 mg/L, respectively. No difference in the parameters at admission was observed in multivariate analysis in distinguishing SAP from MSAP, but the average D-dimer level was significantly different with a cut-off value of 7.268 mg/L by comparing Ranson score, APACHE II score, and D-dimer level.

Conclusions

The average value of D-dimer levels could be used as a predictor of severity of AP. In general, patients with an average D-dimer level <4.868 could be diagnosed with MAP, >7.268 would develop into SAP, and between 4.868 and 7.268 would be MSAP.

Short- and long-term survival after severe acute pancreatitis: A retrospective 17 years' cohort study from a single center

PURPOSE

To study mortality in severe acute pancreatitis (SAP) and to identify risk factors for mortality.

MATERIALS AND METHODS

A retrospective 17-years' cohort study of 435 consecutive adult patients with SAP treated at intensive care unit of a university hospital.

RESULTS

Overall, 357 (82.1%) patients survived at 90 days follow-up. Three-hundred six (89.5%) patients under 60 years, 38 (60.3%) patients between 60 and 69 years, and 13 (43.3%) patients over 69 years of age survived at 90 days follow-up. Independent risk factors for death within 90-days were: 60 to 69 years of age (odds ratio [OR] 5.1), >69 years of age (OR 10.4), female sex (OR 2.0), heart disease (OR 2.9), chronic liver failure (OR 12.3), open abdomen treatment (OR 4.4) and sterile necrosectomy within 4 weeks (OR 14.7). The 10-year survival estimate was <70% in patients under 60 years and <30% in patients over 60 years. Underlying cause of death after the initial 90-day follow-up period was alcohol-related in 48 (57.1%) patients, and all of them had suffered from alcoholic SAP.

CONCLUSIONS

Although younger patients have excellent short-term survival after SAP, the long-term survival estimate is disappointing mostly due to alcohol abuse.

Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis

OBJECTIVE

In patients with pancreatitis, early persisting organ failure is believed to be the most important cause of mortality. This study investigates the relation between the timing (onset and duration) of organ failure and mortality and its association with infected pancreatic necrosis in patients with necrotising pancreatitis.

DESIGN

We performed a post hoc analysis of a prospective database of 639 patients with necrotising pancreatitis from 21 hospitals. We evaluated the onset, duration and type of organ failure (ie, respiratory, cardiovascular and renal failure) and its association with mortality and infected pancreatic necrosis.

RESULTS

In total, 240 of 639 (38%) patients with necrotising pancreatitis developed organ failure. Persistent organ failure (ie, any type or combination) started in the first week in 51% of patients with 42% mortality, in 13% during the second week with 46% mortality and in 36% after the second week with 29% mortality. Mortality in patients with persistent multiple organ failure lasting <1 week, 1-2 weeks, 2-3 weeks or longer than 3 weeks was 43%, 38%, 46% and 52%, respectively (p=0.68). Mortality was higher in patients with organ failure alone than in patients with organ failure and infected pancreatic necrosis (44% vs 29%, p=0.04). However, when excluding patients with very early mortality (within 10 days of admission), patients with organ failure with or without infected pancreatic necrosis had similar mortality rates (28% vs 34%, p=0.33).

CONCLUSION

In patients with necrotising pancreatitis, early persistent organ failure is not associated with increased mortality when compared with persistent organ failure which develops further on during the disease course. Furthermore, no association was found between the duration of organ failure and mortality.

Concordance of the Balthazar Grade and the Revised Atlanta Classification: Proposing a Modified Balthazar Grade to Predict the Severity of Acute Pancreatitis in Pediatric Population

OBJECTIVES

The aim of this study was to compare the concordance of the Balthazar grade and the revised Atlanta classification and then establish a modified radiological scoring system that would predict 3 degrees of severity of acute pancreatitis (AP) based on the latest Atlanta classification.

METHODS

A retrospective study enrolling pediatric inpatients with AP who had completed computed tomography was conducted between January 2006 and March 2018. The concordance of the 2 radiological scoring systems was assessed with κ statistic.

RESULTS

The Balthazar grade was unable to accurately predict the severity of AP compared with the revised Atlanta classification. However, a modified Balthazar grading system defining patents with Balthazar grades A to C as mild, grade D as moderately, and grade E as severe presented perfect agreement with the revised Atlanta classification across the enrolled population (κ, 0.85; 95% confidence interval, 0.73-0.97). The concordance of the modified Balthazar score and the revised Atlanta classification remained a perfect degree of agreement across repeated tests in 90 random samples (κ, 0.85; 95% confidence interval, 0.85-0.85).

CONCLUSIONS

The modified Balthazar grade demonstrated perfect agreement with the latest Atlanta classification for AP severity scoring. As such, the modified Balthazar grade can be used to predict 3 degrees of severity of AP.

Rate of recurrence in Indian patients presenting with acute pancreatitis and identification of chronicity on follow up: Possible risk factors for progression

BACKGROUND

To study the profile and long-term outcome of Indian patients presenting with acute pancreatitis and the possible risk factors for progression.

METHODS

Consecutive patients with acute or recurrent acute pancreatitis seen in our department during July 2013 to December 2014 were included. Details of past episodes were collected and patients were followed up till March 2015.

RESULTS

In the 97 patients included (mean age 47.2 [SD 16.9] years; 74 men), gallstones (37 [38.1%]) and alcohol (19 [19.6%]) were the major identified etiologies; the idiopathic (31 [32%]) group constituted a third of patients. Recurrences were more common with idiopathic etiology (14 patients out of 30 had recurrences [46.7%]) as compared to alcoholic (5 out of 19 [26.3%]) and biliary (4 out of 37 [10.8%]) pancreatitis and with mild index episode. Following the episode of acute pancreatitis, identification of chronic pancreatitis was more common with alcoholic (6 out of 18 [33%]) and idiopathic (9 out of 30 [30%]) etiology as compared to other etiologies. Longer duration of follow up, but not number of recurrent episodes, was associated with identification of chronicity in patients presenting as acute pancreatitis.

CONCLUSIONS

Out of 97 patients with acute pancreatitis, 27 (27.8%) developed recurrences with risk factors being idiopathic etiology and mild index episode. Eighteen of 97 (18.6%) patients had evidence of chronic pancreatitis on follow up, risk factors being the alcoholic and idiopathic varieties, and longer duration of follow up.

Primary and Secondary Organ Failures Cause Mortality Differentially in Acute Pancreatitis and Should be Distinguished

OBJECTIVE

The aim of this study was to study the development of early and late organ failure (OF) and their differential impact on mortality in patients with acute pancreatitis (AP).

METHODS

Consecutive patients (N = 805) with acute pancreatitis were included in an observational study. Organ failure was categorized as primary if it occurred early due to pancreatitis per se and secondary if it occurred late due to infected pancreatic necrosis (IPN). Primary outcome was a relative contribution of primary OF, secondary OF, and IPN to mortality.

RESULTS

Of the 614 patients (mean age, 38.8; standard deviation, 14.6 years; 430 males) in a derivation cohort, 274 (44.6%) developed OF, with 177 having primary OF and 97 secondary OF due to sepsis. Primary OF caused early mortality in 15.8% and was a risk factor for IPN in 76% of patients. Mortality in patients with primary OF and IPN was 49.5% versus 36% in those with IPN and secondary OF (P = 0.06) and 4% in those with IPN but without OF (P < 0.001). The results of the 191 patients in the validation cohort confirmed the relative contribution of primary and secondary OF to mortality.

CONCLUSION

Primary and secondary OF contributed to mortality independently and are distinct in their timing, window of opportunity for intervention, and prognosis.

Association of Systemic Inflammatory and Anti-inflammatory Responses with Adverse Outcomes in Acute Pancreatitis: Preliminary Results of an Ongoing Study

INTRODUCTION

This paper reports preliminary data of an ongoing study that evaluates the association of systemic inflammatory response (SIRS) with early severe acute pancreatitis (ESAP) and compensatory anti-inflammatory response syndrome (characterized by HLA-DR down-regulation) with infected pancreatic necrosis (IPN).

METHODS

Consecutive patients presenting within 72 h of symptom onset with organ dysfunction and/or local complications were included. Following parameters were recorded: demographics, etiology, SIRS, APACHE II, creatinine, BUN. Circulating IL-8, IL-6, IL-10, TNF-alpha concentrations and expression of HLA-DR and IL-10 by qRT-PCR in PBMCs were measured. Strength of associations of cytokine concentration and HLA-DR/IL-10 expression with outcomes was expressed as Hedges' G and relative risk (95% CI).

RESULTS

Twenty-eight patients (10 MSAP; 18 SAP) fulfilled inclusion criteria. Twelve patients had ESAP and eight presented with organ failure. Admission SIRS worsened in eight (28.6%) patients over 48 h. Sixteen (57.1%) patients developed primary IPN. Twenty-one (75%) patients had HLA-DR down-regulation during the first week, which persisted to the second week in 12 (42.9%) patients. IL-8, IL-6, and TNF-α progressively increased from healthy controls to MAP to MSAP to SAP. IL-6 and TNF-α was higher in the patients who developed ESAP (p = 0.01 and 0.05, respectively). Patients who died within the first week also had a significantly elevated concentration of IL-6 and TNF-α (p = 0.02 and 0.01, respectively). The relative risk (95% CI) of developing primary IPN with persistent HLA-DR down-regulation till the second week of illness was 11.3 (1.6-82.4; p = 0.01).

CONCLUSIONS

Our study objectively demonstrates significant association of ESAP and early mortality with primary cytokine response, and development of IPN with persistent HLA-DR down-regulation.

Acinar injury and early cytokine response in human acute biliary pancreatitis

Clinical acute pancreatitis (AP) is marked by an early phase of systemic inflammatory response syndrome (SIRS) with multiorgan dysfunction (MODS), and a late phase characterized by sepsis with MODS. However, the mechanisms of acinar injury in human AP and the associated systemic inflammation are not clearly understood. This study, for the first time, evaluated the early interactions of bile acid induced human pancreatic acinar injury and the resulting cytokine response. We exposed freshly procured resected human pancreata to taurolithocolic acid (TLCS) and evaluated for acinar injury, cytokine release and interaction with peripheral blood mononuclear cells (PBMCs). We observed autophagy in acinar cells in response to TLCS exposure. There was also time-dependent release of IL-6, IL-8 and TNF-α from the injured acini that resulted in activation of PBMCs. We also observed that cytokines secreted by activated PBMCs resulted in acinar cell apoptosis and further cytokine release from them. Our data suggests that the earliest immune response in human AP originates within the acinar cell itself, which subsequently activates circulating PBMCs leading to SIRS. These findings need further detailed evaluation so that specific therapeutic targets to curb SIRS and resulting early adverse outcomes could be identified and tested.

Endoscopic management of pancreatic fluid collections-revisited

The development of pancreatic fluid collections (PFC) is one of the most common complications of acute severe pancreatitis. Most of the acute pancreatic fluid collections resolve and do not require endoscopic drainage. However, a substantial proportion of acute necrotic collections get walled off and may require drainage. Endoscopic drainage of PFC is now the preferred mode of drainage due to reduced morbidity and mortality as compared to surgical or percutaneous drainage. With the introduction of new metal stents, the efficiency of endoscopic drainage has improved and the task of direct endoscopic necrosectomy has become easier. The requirement of re-intervention is less with new metal stents as compared to plastic stents. However, endoscopic drainage is not free of adverse events. Severe complications including bleeding, perforation, sepsis and embolism have been described with endoscopic approach to PFC. Therefore, the endoscopic management of PFC is a multidisciplinary affair and involves interventional radiologists as well as GI surgeons to deal with unplanned adverse events and failures. In this review we discuss the recent advances and controversies in the endoscopic management of PFC.

Revised Atlanta classification and determinant-based classification: Which one better at stratifying outcomes of patients with acute pancreatitis?

BACGROUND

Two different severity classifications (revised Atlanta classification [RAC] and determinant-based classification [DBC]) were recently proposed.

METHODS

This was a retrospective analysis of a prospective acute pancreatitis (AP) database. This study aims to compare the ability of three classification systems (RAC, DBC, and original Atlanta classification [OAC]) to stratify outcomes of AP and to determine the association between different severity categories and clinical outcomes.

RESULTS

Overall, as the grade of severity increased, the morbidity and mortality increased accordingly in the three classification systems. The RAC and DBC were comparable, but performed better than OAC in predicting mortality (AUC 0.92 and 0.95 vs. 0.66, p < 0.001), ICU admission (AUC 0.92 and 0.96 vs. 0.68, p < 0.001), ICU LOS (AUC 0.73 and 0.76 vs. 0.50, p < 0.001), and hospital stay (AUC 0.81 and 0.83 vs. 0.70, p < 0.001). The DBC performed better than the RAC and OAC in predicting the need for intervention (AUC 0.87 vs. 0.79 and 0.68, p < 0.05). The mortality rate in patients with critical DBC category was higher than that in those with severe RAC category (42.1% vs. 24.7%; p = 0.008). POF (OR 19.4, p = 0.001) and IN (OR 11.0, p = 0.025) were independent risk factors for mortality.

CONCLUSIONS

In tertiary referral setting, patients in the critical category are at the greatest risk for death and should be managed in an intensive care unit. Although IN itself may be less influential on mortality than POF, IN as well as POF should be considered as the key determinants for severity stratification.

Management and outcomes of acute pancreatitis patients over the last decade: A US tertiary-center experience

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) management remains largely supportive and can be challenging in patients with severe disease. This study aims to describe a ten-year US tertiary-center experience in managing AP patients.

METHODS

Clinical management and outcomes of 400 prospectively enrolled AP patients stratified by the Revised Atlanta Classification were analyzed; trends in management between early (2004-2008) and late enrollment phase (2009-2014) were assessed.

RESULTS

Fifty-two% of patients were classified as mild AP (MAP); moderately severe (MoAP) and severe (SAP) grades contained 23.5% and 24.5% of participants. Intravenous fluid administration during the first 24 h (MAP 3.7, MoAP 4.7, and SAP 4.8 L), need for ICU (6%, 23%, 93%), and nutritional support (7%, 51%, 90%) increased significantly with greater AP severity (p < 0.001). One hundred fifty five (39%) patients developed necrotizing AP, of which 41% received prophylactic antibiotics, and 44% underwent pancreatic drainage/debridement. Prophylactic antibiotics (58% vs. 27%) and interventions (63% vs. 27%) were noted more frequently in SAP than MoAP (p < 0.001). Enteral nutrition (18% vs. 30%) and minimally invasive pancreatic interventions (19% vs. 41%) were more commonly used in the late phase (p < 0.05). The overall median length of hospitalization was 7 days reaching 29 days in SAP group. Mortality was 5%; all deaths occurred in SAP group.

CONCLUSIONS

This study provides an extensive report on clinical management of AP and its trends overtime. Pancreatic intervention is required in less than 50% of patients with necrotizing pancreatitis. Utilization of enteral nutrition and minimally invasive pancreatic interventions has been increasing over time.

Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification?

OBJECTIVE

To compare the classification performance of the Revised Atlanta Classification, the Determinant-Based Classification, and a new modified Determinant-Based Classification according to observed mortality and morbidity.

DESIGN

A prospective multicenter observational study conducted in 1-year period.

SETTING

Forty-six international ICUs (Epidemiology of Acute Pancreatitis in Intensive Care Medicine study).

PATIENTS

Admitted to an ICU with acute pancreatitis and at least one organ failure.

INTERVENTIONS

Modified Determinant-Based Classification included four categories: In group 1, patients with transient organ failure and without local complications; in group 2, patients with transient organ failure and local complications; in group 3, patients with persistent organ failure and without local complications; and in group 4, patients with persistent organ failure and local complications.

MEASUREMENTS AND MAIN RESULTS

A total of 374 patients were included (mortality rate of 28.9%). When modified Determinant-Based Classification was applied, patients in group 1 presented low mortality (2.26%) and morbidity (5.38%), patients in group 2 presented low mortality (6.67%) and high morbidity (60.71%), patients in group 3 presented high mortality (41.46%) and low morbidity (8.33%), and patients in group 4 presented high mortality (59.09%) and morbidity (88.89%). The area under the receiver operator characteristics curve of modified Determinant-Based Classification for mortality was 0.81 (95% CI, 0.77-0.85), with significant differences in comparison to Revised Atlanta Classification (0.77; 95% CI, 0.73-0.81; p < 0.01), and Determinant-Based Classification (0.77; 95% CI, 0.72-0.81; p < 0.01). For morbidity, the area under the curve of modified Determinant-Based Classification was 0.80 (95% CI, 0.73-0.86), with significant differences in comparison to Revised Atlanta Classification (0.63, 95% CI, 0.57-0.70; p < 0.01), but not in comparison to Determinant-Based Classification (0.81, 95% CI, 0.74-0.88; nonsignificant).

CONCLUSION

Modified Determinant-Based Classification identified four groups with different clinical presentation in patients with acute pancreatitis in ICU, with better discriminatory power in comparison to Determinant-Based Classification and Revised Atlanta Classification.

New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis

BACKGROUND

The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity according to the presence of local and/or systemic complications and presence and length of organ failure. No study focused on complications and mortality of patients with moderately severe AP admitted to intensive care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these patients and compare them to those with severe AP.

METHODS

Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical-surgical ICU during 5years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality.

RESULTS

Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed some kind of complications without differences on complications rate between moderately severe or severe AP. All the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs. 79.5% on severe, p=0.0443). None of the patients with moderately severe AP died during their intensive care unit stay vs. 29.5% with severe AP (p=0.049).

CONCLUSIONS

Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of pancreatitis according to their severity.

Acute Pancreatitis: Landmark Studies, Management Decisions, and the Future

A great deal of progress has been made in the last 50 years in the diagnosis and treatment of acute pancreatitis. Many landmark studies have been published and have focused on the classification of acute pancreatitis, markers of severity, important roles of imaging and endoscopy, and improvements in our treatment. This report will review several landmark studies, describe ongoing controversies in management decisions including standards of early fluid resuscitation and appropriate use of enteral feeding, and outline what will be required in the future to improve the care of patients with acute pancreatitis.

Admission, management and outcomes of acute pancreatitis in intensive care

BACKGROUND

A review of the management of acute pancreatitis (AP) at a tertiary intensive care unit (ICU) in Auckland, New Zealand, was published in 2004. This paper aims to update this series and identify changes in admission criteria, management and outcomes.

METHODS

A retrospective review of patients admitted to the Department of Critical Care Medicine, Auckland City Hospital, with AP from 2003 to 2014 was undertaken and data compared with the previous study (1988-2001).

RESULTS

Eighty-four patients (male 53, mean ± SD age = 56.9 ± 15 years) with 85 admissions to ICU from 2003 to 2014 were compared with 112 patients in the previous study. Maori were over-represented. Median duration of symptoms prior to admission to ICU decreased from 7 to 3 days. The proportion of total AP patients admitted to ICU halved and the mean Acute Physiology and Chronic Health Evaluation II score on admission decreased from mean 19.9 ± 8.2 SD to 15.4 ± 7.3 (P < 0.001). Two thirds of patients had persistent organ failure. The use of enteral feeding doubled from 46/112 (41%) to 71/85 (84%) (P < 0.001). The use of primary percutaneous drainage increased from 14/112 (13%) to 24/85 (28%) (P = 0.007). Rate of necrosectomy was similar (36/112 (32%) versus 20/85 (24%), P = 0.205), although minimally invasive necrosectomy was introduced. Overall hospital mortality decreased by 29% (P = 0.198).

CONCLUSION

There have been changes to the admission criteria and management in line with evolving guidelines and, overall, outcomes have improved.

Prevalence of Splanchnic Vein Thrombosis in Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

Splanchnic vein thrombosis (SVT) may be negatively associated with the prognosis of pancreatitis. We performed a systematic review and meta-analysis of literatures to explore the prevalence of SVT in pancreatitis. All observational studies regarding the prevalence of SVT in pancreatitis were identified via PubMed and EMBASE databases. The prevalence of SVT was pooled in the total of patients with pancreatitis. And it was also pooled in the subgroup analyses according to the stage and causes of pancreatitis, location of SVT, and regions where the studies were performed. After the review of 714 studies, 44 studies fulfilled the inclusion criteria. Meta-analyses showed a pooled prevalence of SVT of 13.6% in pancreatitis. According to the stage of pancreatitis, the pooled prevalence of SVT was 16.6% and 11.6% in patients with acute and chronic pancreatitis, respectively. According to the causes of pancreatitis, the pooled prevalence of SVT was 12.2% and 14.6% in patients with hereditary and autoimmune pancreatitis. According to the location of SVT, the pooled prevalence of portal vein, splenic vein, and mesenteric vein thrombosis was 6.2%, 11.2%, and 2.7% in pancreatitis. The prevalence of SVT in pancreatitis was 16.9%, 11.5%, and 8.5% in Europe, America, and Asia, respectively.

Acute pancreatitis

PURPOSE OF REVIEW

To summarize recent data on classification systems, cause, risk factors, severity prediction, nutrition, and drug treatment of acute pancreatitis.

RECENT FINDINGS

Comparison of the Revised Atlanta Classification and Determinant Based Classification has shown heterogeneous results. Simvastatin has a protective effect against acute pancreatitis. Young black male, alcohol, smoldering symptoms, and subsequent diagnosis of chronic pancreatitis are risk factors associated with readmissions after acute pancreatitis. A reliable clinical or laboratory marker or a scoring system to predict severity is lacking. The PYTHON trial has shown that oral feeding with on demand nasoenteric tube feeding after 72 h is as good as nasoenteric tube feeding within 24 h in preventing infections in predicted severe acute pancreatitis. Male sex, multiple organ failure, extent of pancreatic necrosis, and heterogeneous collection are factors associated with failure of percutaneous drainage of pancreatic collections.

SUMMARY

The newly proposed classification systems of acute pancreatitis need to be evaluated more critically. New biomarkers are needed for severity prediction. Further well designed studies are required to assess the type of enteral nutritional formulations for acute pancreatitis. The optimal minimally invasive method or combination to debride the necrotic collections is evolving. There is a great need for a drug to treat the disease early on to prevent morbidity and mortality.

Antibiotic use in acute pancreatitis: an Indian multicenter observational study

INTRODUCTION

Prophylactic antibiotics are used frequently for acute pancreatitis (AP). Consensus guidelines do not recommend this currently, based on moderate quality evidence. In this study, we aimed to evaluate the antibiotic use pattern in AP in India and propose a risk-directed approach to antibiotic use in AP.

MATERIAL AND METHODS

This multicenter study was conducted from 1 May 2013 to 31 July 2013. Eleven participants from eight tertiary centers completed a questionnaire that captured patient demographics, etiology, admission status, presence of (peri)pancreatic necrosis, severity of pancreatitis, details of antibiotic use, and clinical outcomes (total hospital stay, persistent organ failure, need for ICU, total days in ICU, development of infections, in-hospital mortality).

RESULTS

A total of 200 proformas were analyzed. Seventy-three (36.5 %) had acute necrotizing pancreatitis (ANP). Eighty-nine (44.5 %), 52 (26 %), and 55 (27.5 %) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. Forty-five (22.5 %) patients developed infections (unifocal 29; multifocal 16). One hundred thirty-four (67 %) patients received antibiotics, of which 89 (66.4 %) received prophylactic, while 45 (33.6 %) received therapeutic antibiotics. The distribution of antibiotic use according to the severity of AP was 43 (48.3 %) in patients with MAP (prophylactic in 41; therapeutic in 2), 36 (69.2 %) in patients with MSAP (prophylactic in 29; therapeutic in 7), and 55 (100 %) in patients with SAP (prophylactic in 19; therapeutic in 36). Therapeutic antibiotics were prescribed based on culture and sensitivity in 21 (46.7 %) patients.

CONCLUSIONS

Despite nonrecommendation, prophylactic antibiotics are used frequently in AP. We emphasize on the need for multicenter randomized controlled trials on prophylactic antibiotics for AP based on a risk-directed approach, rather than a "blanket approach."