Predictors and outcomes of moderately severe acute pancreatitis - Evidence to reclassify

Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis

OBJECTIVE

Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission.

DESIGN

Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated.

RESULTS

After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP.

CONCLUSIONS

The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts.

TRIAL REGISTRATION NUMBER

NCT04777812.

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.

Acute Pancreatitis as an Unusual Culprit of Diabetic Ketoacidosis in a Nondiabetic: A Case-Based Review

Acute pancreatitis has been associated with a multitude of complications including pancreatic necrosis, pseudocysts, abscesses, acute respiratory distress syndrome, disseminated intravascular coagulation, and hyperglycemia. To date, only rare case reports have demonstrated diabetic ketoacidosis (DKA) as a rare sequela of acute pancreatitis. We report a case of a 34-year-old female with no prior history of diabetes who was subsequently diagnosed with DKA after presenting with severe acute pancreatitis. This case serves as a framework to not only highlight DKA as a rare complication of acute pancreatitis but also to explore the potential pathophysiology that underlies this phenomenon including stress hyperglycemia and post-pancreatitis diabetes mellitus.

Course of Acute Pancreatitis Patients with Renal Failure According to Balthazar Classification

Background and Aim

There are criteria that include many organ systems to predict the prognosis in acute pancreatitis (AP) patients. In this study, we aimed to show how the course of the disease changes according to the Balthazar classification in AP patients presenting with renal failure.

Methods and Materials

Our study included 352 patients who were admitted to the Emergency Service of our hospital and were diagnosed and hospitalized with AP. According to the Balthazar score, patients with scores of 0-2, 4-6, and 8-10 were evaluated as mild, moderate, and severe AP, respectively. Demographic data (age, gender) of all patients were documented. The etiology of AP was determined in all patients. Biliary, drug/toxic, alcohol, infections, hyperlipidemia, post-endoscopic retrograde cholangiopancreatography (ERCP), genetics, hypercalcemia, structural anomalies, and malignancy were evaluated as the etiology. Those without any underlying pathology were evaluated as idiopathic AP. The patients were divided into two groups as those with and without renal insufficiency. All patients underwent helical computed tomography (section 64, Aquilion; Toshiba Medical Systems, Tokyo) within the first 12 hours and between days 3 and 7. Pancreas, peripancreatic and extrapancreatic findings, and complications were examined. "The Statistical Package for the Social Sciences 19.0 (SPSS Armonk, NY: IBM Corp.)" was used for all analyses. Kolmogorov-Smirnov test and histograms were used to determine whether there was a normal distribution. The non-parametric data of the groups were compared using the Mann-Whitney U test and the parametric data using the ındependent t test. Chi-square test was used to test categorical data. Cases with P < 0.05 were considered statistically significant.

Results

: While 22 (6.2%) patients had renal insufficiency, 332 (95.8%) patients did not have renal insufficiency. In the evaluation made in terms of AP severity; according to Balthazar classification at admission, there was no difference in mild and moderate pancreatitis for kidney insufficiency in both groups, but it was significantly higher in the group with severe pancreatitis [2 (9.1%) versus 1 (0.3%), P < 0.001]. In the evaluation made after 72 hours; renal failure was significantly lower in the group with mild pancreatitis [11 (50.0%) versus 245 (73.8%), P: 0.016] and severe renal failure was significantly higher in severe pancreatitis [7 (31.8%) versus 13 (%) 3.9), P < 0.001].

Conclusions

Early intensive care unit admission and close follow-up and early treatment in AP patients change the course of the disease. In our study, we showed that serum creatinine level is an important parameter in the course of AP and has a predictive value for the course of the disease.

Severe, Complicated Pancreatitis With an Unclear Etiology

Acute pancreatitis is an inflammatory process. There can be many causes of pancreatitis, which include alcohol or gallstones but can also be due to hypercalcemia, infections, or hypertriglyceridemia. Most cases of pancreatitis are mild and without complications. Severe cases of pancreatitis can cause complications, including organ failure. Pseudocysts are a rare complication of pancreatitis and may require management. We present a patient with severe acute pancreatitis with organ failure admitted to the intensive care unit, stabilized, and required subsequent management of a pseudocyst with cystogastrostomy with a lumen-apposing metal stent. The patient subsequently improved and is doing well today. Herein, we present an acute severe pancreatitis case report with an extensive workup complicated by pseudocyst development. We review pancreatitis causes, including rare causes and management.

Revisiting the Ranson score in acute pancreatitis: Is the drop in hematocrit a worrisome sign?

BACKGROUND

The Ranson score has 11 parameters that are complex and laborious to implement. In this study, we aimed to create a revised Ranson score by modifying the parameters in Ranson.

METHODS

A total of 938 patients diagnosed with acute pancreatitis (AP) between 2014 and 2021 were included in the study. The parameters of the Ranson score were included in the univariate and multivariate analyses. According to the results, some of these parameters were modified, and then the revised Ranson score was created.

RESULTS

The revised Ranson system was created with nine parameters by modifying the hematocrit parameter at 48 hours and excluding the aspartate aminotransferase parameter from the scoring system. For in-hospital mortality, the area under the curve value of the revised Ranson was 0.959 (95% CI: 0.931-0.986), and it was significantly higher compared to the three scoring systems evaluated. At a cut-off value of 3.5, the revised Ranson had a sensitivity and specificity of 91.7% and 89.1%, respectively, for mortality.

CONCLUSION

The revised Ranson scoring system had better predictive ability for all clinical outcomes compared to the original Ranson in our large sample of 938 patients. However, the revised version should be further validated by prospective and multicenter studies.

Comprehensive meta-analysis of randomized controlled trials of Lactated Ringer's versus Normal Saline for acute pancreatitis

INTRODUCTION

Fluid resuscitation is the keystone of treatment for acute pancreatitis. Though clinical guidelines and expert opinions agree on large volume resuscitation, debate remains on the optimal fluid type. The most commonly used fluids are Lactated Ringer's (LR) and Normal Saline (NS), but the studies published to date comparing LR vs NS yield conflicting results. We aimed to identify and quantitatively synthesize existing high quality data of the topic of fluid type or acute pancreatitis resuscitation.

METHODS

In collaboration with the study team, an information specialist performed a comprehensive literature review to identify reports addressing type of fluid resuscitation. Studies were screened using the Covidence system by two independent reviewers in order to identify Randomized controlled trials comparing LR versus NS. The main outcome was the development of moderately severe or severe pancreatitis and additional outcomes included local complications, ICU admission, and length of stay. Pooled odds ratios were estimated using the random effects model and standardized mean difference to compare continuous variables.

RESULTS

We reviewed 7964 abstracts and 57 full text documents. Four randomized controlled trials were identified and included in our meta-analyses. There were a total of 122 patients resuscitated with LR versus 126 with NS. Patients resuscitated with LR were less likely to develop moderately severe/severe pancreatitis (OR 0.49; 95 % CI 0.25-0.97). There was no difference in development of SIRS at 24 or 48 h or development of organ failure between the two groups. Patients resuscitated with LR were less likely to require ICU admission (OR 0.33; 95 % CI 0.13-0.81) and local complications (OR 0.42; 95 % CI 0.2-0.88). While there was a trend towards shorter hospitalizations for LR (SMD -0.18, 99 % CI -0.44-0.07), it was not statistically significant.

CONCLUSION

Resuscitation with LR reduces the development of moderately severe-severe pancreatitis relative to NS. Nevertheless, no difference in SIRS development or organ failure underscores the need for further studies to verify this finding and define its mechanism.

Predictors of prolonged hospitalization in patients with mild and moderate pancreatitis presenting to the emergency department

BACKGROUND

Patients with acute pancreatitis often present to the emergency department (ED) and usually require hospital admission. The aim of this study was to determine predictors of prolonged hospital stays in patients with mild forms of acute pancreatitis.

METHODS

This retrospective cohort study was conducted in patients diagnosed in the ED with mild and moderate acute pancreatitis according to the revised Atlanta classification. Patients with available data between 2007 and 2017 were included and were divided based on their admission duration. Eight days or more was considered a long hospitalization. A multivariate logistic regression model was constructed to determine the independent predictors of prolonged hospital stays.

RESULTS

Of the 485 evaluated patients, 335 were included in the analysis. Baseline characteristics, determined by vital signs and laboratory parameters, were similar between the short and long hospitalization groups. However, the long hospitalization group received more intravenous crystalloid in the ED, and this group used more diuretics and more angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker (ACEI/ARB) drugs than the other group. Diuretic use was present in 8 patients (4.8%) in the short hospital length of stay group and in 26 patients (15.3%) in the long hospital length of stay group. Age, gender, ACEI/ARB use, diuretic use, total amount of intravenous crystalloid administered in the ED, aPTT, BUN, creatinine, and presence of biliary pathology were included in the multivariate analysis. Regarding the final analysis, diuretic use was an independent predictor of prolonged hospitalization (odds ratio 2.89, 95% confidence interval 1.05-8.00, p = 0.041).

CONCLUSION

Diuretic use is an independent predictor of long hospitalization in patients with mild and moderate pancreatitis. Drugs affecting total volume balance may prolong hospital stays in these patients.

The Short- and Long-Term Burden of Acute Pancreatitis in the United States: A Retrospective Cohort Study

OBJECTIVES

This retrospective cohort study assessed short- and long-term economic, clinical burden, and productivity impacts of acute pancreatitis (AP) in the United States.

METHODS

United States claims data from patients hospitalized for AP (January 1, 2011-September-30, 2016) were sourced from MarketScan databases. Patients were categorized by index AP severity: severe intensive care unit (ICU), severe non-ICU, and other hospitalized patients.

RESULTS

During index, 41,946 patients were hospitalized or visited an emergency department for AP. For inpatients, median (interquartile range) AP-related total cost was $13,187 ($12,822) and increased with AP severity (P < 0.0001). During the postindex year, median AP-related costs were higher (P < 0.0001) for severe ICU versus severe non-ICU and other hospitalized patients. Hours lost and costs due to absence and short-term disability were similar between categories. Long-term disability costs were higher (P = 0.005) for severe ICU versus other hospitalized patients. Factors associated with higher total all-cause costs in the year after discharge included AP severity, length of hospitalization, readmission, AP reoccurrence, progression to chronic pancreatitis, or new-onset diabetes (P < 0.0001).

CONCLUSIONS

An AP event exerts substantial burden during hospitalization and involves long-term clinical and economic consequences, including loss of productivity, which increase with index AP event severity.

Acute pancreatitis in Chile: A multicenter study on epidemiology, etiology and clinical outcome. Retrospective analysis of clinical files

BACKGROUND

Epidemiology of acute pancreatitis (AP) is variable in different geographical regions.

OBJECTIVES

To compare etiology and severity of AP to published data from South America and the rest of world, study impact of demographical factors and treatment on its outcome in Chilean hospitals.

METHODS

Multicenter observational study. Data of consecutive patients with AP were collected at the moment of discharge from 11 centers and retrospectively analyzed.

RESULTS

Data of 962 patients were included in the analysis, 447 men and 515 women. Mean age was 48,2 years. Biliary etiology was significantly more frequent in women (70%) than in men (52%). Conversely, alcohol was responsible for about 17% of AP in men but exceptional in women. Mild AP was seen in 73.4%, moderately severe in 14.1% and severe in 13%. The overall mortality was 2.5% (24 of 962): 0.3%, 3.1% and 15.1% in mild, moderately severe and severe cases, respectively. No difference was found in the mortality and severity of biliary versus alcoholic AP, while hypertriglyceridemia induced AP was more severe, without increased mortality. Severity and mortality increased with age. ERCP was performed in 16% of biliary pancreatitis. Adherence to main guidelines was heterogeneous: more than half of mild AP patients were admitted to critical care units and antibiotics were used in about 25% them.

CONCLUSION

This is the first multicenter study in Chile on AP. When compared to literature, we found similar severity distribution and an acceptably low mortality. Biliary etiology was dominant, but alcohol was also important in men.

Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial

BACKGROUND

Two strategies for same-admission cholecystectomy in mild gallstone pancreatitis (MGP) exist: early surgery (within 48-72 h from admission) and delayed surgery until resolution of symptoms and normalization of pancreatic tests.

METHODS

This was a single-center, open-label RCT. Patients with MGP according to revised Atlanta classification-2012 and SIRS criteria were randomly assigned to early laparoscopic cholecystectomy (E-LC) within 72 h from admission or delayed laparoscopic cholecystectomy (D-LC). Laparoscopic-endoscopic rendezvous was performed when common bile duct stones were found at systematic intraoperative cholangiography. The primary outcome was length of stay (LOS), and the secondary outcomes were complications at 90 days, need for ERCP/choledocolithiasis, conversion, and re-admission. One year of follow-up was carried-on.

RESULTS

At interim analysis, 52 patients were randomized (26 E-LC, 26 D-LC). E-LC versus D-LC was associated with a significantly shorter LOS (median 58 versus 167 h; P = 0.001). There were no differences in ERCP necessity for choledocolithiasis between the two approaches (E-LC 26.9% versus D-LC 23.1%, P = 1.00). No differences in postoperative complications were found.

CONCLUSIONS

E-LC approach in patients with MGP significantly reduced LOS and was not associated with clinically relevant postoperative complications.

TRIAL REGISTRATION

clinicaltrials.gov (NCT02590978).

Type 2 diabetes and chronic kidney disease as important prognostic factors in acute pancreatitis

This study includes an analysis of acute pancreatitis (AP) prognostic factors was performed as well as a critical review of the most important AP prognostic scales (APACHE II, Ranson, BISAP, SOFA, Marshall). The limitations of each scale were described. Simultaneously, the clinical applicability in the early prognostic AP stratification was presented, along with the clinical value of the alcoholic and gallstones etiology in the differential diagnosis. Pre-existing type 2 diabetes and chronic kidney disease significantly worsen the course of AP and should be included in the prognostic scale. It was shown that the diabetes coexisting with a HBA1C level above 6.5% significantly increases the mortality of AP patients and prolongs the period of hospitalization for 5 days. It was also observed that chronic kidney disease significantly increases the frequency of infective AP complications and raises 3-months mortality.

Modified Da-chai-hu Decoction regulates the expression of occludin and NF-κB to alleviate organ injury in severe acute pancreatitis rats

Modified Da-chai-hu Decoction (MDD), a traditional Chinese medicinal formulation, which was empirically generated from Da-chai-hu decoction, has been utilized to treat severe acute pancreatitis (SAP) for decades. The aim of the present study was to explore its potential organprotective mechanism in SAP. In the present study, rat SAP model was induced by retrograde injection of 3.5% sodium taurocholate into the biliopancreatic duct, MDD (23.35 g/kg body weight, twelve times the clinical dose) were orally given at 2 h before and 10 h after injection. At 12 h after model induction, blood was taken from vena cava for analysis of amylase, diamine oxidase (DAO), pulmonary surfactant protein-A (SP-A), and C-reactive protein (CRP). Histopathological change of pancreas, ileum and lung was assayed by H&E staining, myeloperoxidase (MPO) activity were determinated using colorimetric assay, and the expressions of occludin and nuclear factor-κB (NF-κB) were detected by real-time RT-PCR and western blot, respectively. In addition, the tissue concentrations of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and monocyte chemoattractant protein-1 (MCP-1) were measured by enzyme-linked immunosorbent assay (ELISA). The results showed that in SAP rats, MDD significantly alleviated histopathological damage, depressed the MPO activity and the concentrations of TNF-α, IL-1β, and MCP-1 of pancreas, ileum and lung, and reduced the serum levels of amylase [(3283.4 ± 585.5) U·L^-1vs (5626.4 ± 795.1)U·L^-1], DAO [(1100.1 ± 334.3) U·L^-1vs (1666.4 ± 525.3) U·L^-1] and CRP [(7.6 ± 1.2) μg·mL^-1vs (17.8 ± 3.8) μg·mL^-1]. However, the serum SP-A concentration [(106.1 ± 16.6) pg·mL^-1vs (90.1 ± 14.9) pg·mL^-1] was elevated when treated SAP rats with MDD. Furthermore, MDD increased the occludin expression and reduced the NF-κB expression in pancreas, ileum and lung of SAP rats. Our findings suggested that MDD administration was an effective therapeutic approach for SAP treatment. It could up-regulate occludin expression to protect intercellular tight junction and down-regulate NF-κB expression to inhibit inflammatory reaction of pancreas, ileum and lung.

Moderately severe and severe acute pancreatitis : a systematic review of the outcomes in the USA and European Union-5

Background and objectives

The global incidence of hospitalisation due to acute pancreatitis (AP) has been rising in the recent decades. In the USA alone, there was a 13.2% increase between 2009 and 2012 compared with 2002–2005. There remains a lack of approved treatments to prevent disease progression, leaving many liable to developing complications that include multisystem organ failure (OF) and death. This therapeutic deficit raises questions about the scale of the current burden of illness (BOI) associated with severe forms of AP. The aim of the systematic literature review (SLR) was to assess clinical, humanistic, and economic outcomes associated with moderately severe AP (MSAP) and severe AP (SAP) in the USA and the European Union-5 (EU-5).

Methods

Systematic searches were conducted in MEDLINE and Embase to identify studies published in English (between 2007 and 2017) that reported on the BOI of MSAP and/or SAP. Manual searches of ‘grey’ literature sources were also conducted.

Results

The SLR identified 19 studies which indicated that 15%–20% of patients with AP progress to more severe forms of the disease, up to 10.5% of those with SAP require surgery for complications, and up to 40% die during hospitalisation. By contrast, there appears to be a lack of data on the extent to which SAP affects patients’ quality of life.

Conclusion

The available evidence clearly demonstrates that the current management for MSAP and SAP in the USA and EU-5 does not adequately meet patients’ needs. Early identification and intervention for AP is crucial, given the evidence of high rates of morbidity and an associated economic burden that is considerable. Since many patients with the condition present to hospitals at a point when multisystem OF or death is highly likely, there is a particularly urgent need for effective treatment options to prevent disease progression.

Characterization of long-term prognosis in acute pancreatitis: An explorative analysis

BACKGROUND/OBJECTIVES

Severity classification systems of acute pancreatitis (AP) assess inpatient morbidity and mortality without predicting outpatient course of AP. To provide appropriate outpatient care, determinants of long-term prognosis must also be identified. The aim of this study was to define clinical groups that carry long-term prognostic significance in AP.

METHODS

A retrospective study that included patients admitted with AP was conducted. Determinants of long-term prognosis were extracted: These included Revised Atlanta and Determinant Based Classification (RAC), Charlson Comorbidity Index (CCI), Modified CT Severity Index (MCTSI), etiology, and local complications (LCs). Seven surrogates of morbidity up to 1 year after discharge were also collected and subsequently imputed into a clustering algorithm. The algorithm was set to produce three categories and multinomial regression analysis was performed.

RESULTS

281 patients were included. The incidences of morbidity endpoints were similar among the 3 RAC categories. Three clusters were identified that carried long-term prognostic significance. Each cluster was given a name to reflect prognosis. The limited AP had the best prognosis and included patients without LCs with a low co-morbidity burden. The brittle AP had a low co-morbidity burden and high MCTSI (LCs 94%). It ran a very morbid course but had excellent survival. The high-risk AP had the worst prognosis with the highest mortality rate (28%). They had a high co-morbidity burden without local complications.

CONCLUSION

Categories that carry long-term prognostic significance in AP have been developed. This study could help formulate appropriate follow-up and ultimately improve AP outcomes.

Natural History of Gas Configurations and Encapsulation in Necrotic Collections During Necrotizing Pancreatitis

BACKGROUND

Decision-making on invasive intervention in patients with clinical signs of infected necrotizing pancreatitis is often related to the presence of gas configurations and the degree of encapsulation in necrotic collections on imaging. Data on the natural history of gas configurations and encapsulation in necrotizing pancreatitis are, however, lacking.

METHODS

A post hoc analysis was performed of a previously described prospective cohort in 21 Dutch hospitals (2004-2008). All computed tomography scans (CTs) performed during hospitalization for necrotizing pancreatitis were categorized per week (1 to 8, and thereafter) and re-assessed by an abdominal radiologist.

RESULTS

A total of 639 patients with necrotizing pancreatitis were included, with median four (IQR 2-7) CTs per patient. The incidence of first onset of gas configurations varied per week without a linear correlation: 2-3-13-11-10-19-12-21-12%, respectively. Overall, gas configurations were found in 113/639 (18%) patients and in 113/202 (56%) patients with infected necrosis. The incidence of walled-off necrosis increased per week: 0-3-12-39-62-76-93-97-100% for weeks 1-8 and thereafter respectively. Clinically relevant walled-off necrosis (largely or fully encapsulated necrotic collections) was seen in 162/379 (43%) patients within the first 3 weeks.

CONCLUSIONS

Gas configurations occur in every phase of the disease and develop in half of the patients with infected necrotizing pancreatitis. Opposed to traditional views, clinically relevant walled-off necrosis occurs frequently within the first 3 weeks.

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

BACKGROUND

The aim of our study was to determine the risk factors for extrapancreatic infection (EPI) occurrence and its predictive power for assessing severity and local complications in acute pancreatitis including infected pancreatic necrosis (IPN).

METHODS

Clinical data of 176 AP patients prospectively enrolled were analysed. EPI analysed were bacteraemia, lung infection, urinary tract infection and catheter line infection. Risk factors analysed were: Leukocyte count, C-reactive protein, liver function test, serum calcium, serum glucose, Blood urea nitrogen, mean arterial pressure at admission, total parenteral nutrition (TPN), enteral nutrition, hypotension, respiratory, cardiovascular and renal failure at admission, persistent systemic inflammatory response (SIRS) and intrapancreatic necrosis. Severity outcomes assessed were defined according to the Atlanta Criteria definition for acute pancreatitis. The predictive accuracy of EPI for morbidity and mortality was measured using area-under-the-curve (AUC) receiver-operating characteristics.

RESULTS

Forty-four cases of EPI were found (25%). TPN (OR:9.2 CI95%: 3.3-25.7), APACHE-II>8 (OR:6.2 CI95%:2.48-15.54) and persistent SIRS (OR:2.9 CI95%: 1.1-7.8), were risk factors related with EPI. Bacteraemia, when compared with others EPI, showed the best accuracy in predicting significantly persistent organ failure (AUC:0.76, IC95%:0.64-0.88), ICU admission (AUC:0.80 IC95%:0.65-0.94), and death (AUC:0.73 CI95%:0.54-0.91); and for local complications including IPN (AUC:0.72 CI95%:0.53-0.92) as well. Besides, it was also needed for an interventional procedure against necrosis (AUC:0.74 IC95%: 0.57-0.91). When bacteraemia and IPN occurs, bacteraemia preceded infected necrosis in all cases. On multivariate analysis, risk factor for IPN were lung infection (OR:6.25 CI95%1.1-35.7 p = 0.039) and TPN (OR:22.0CI95%:2.4-205.8, p = 0.007), and for mortality were persistent SIRS at first week (OR: 22.9 CI95%: 2.6-203.7, p = 0.005) and Lung infection (OR: 9.7 CI95%: 1.7-53.8).

CONCLUSION

In our study, EPI, played a role in predicting the severity and local complications in acute pancreatitis.

How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification

AIM

To explore the outcomes and the appropriate treatment for patients with moderately severe acute pancreatitis (AP).

METHODS

Statistical analysis was performed on data from the prospectively collected database of 103 AP patients admitted to the Department of Surgery, Hospital of Lithuanian University of Health Sciences in 2008-2013. All patients were confirmed to have the diagnosis of AP during the first 24 h following admission. The severity of pancreatitis was assessed by MODS and APACHE II scale. Clinical course was re-evaluated after 24, 48 and 72 h. All patients were categorized into 3 groups based on Atlanta 2012 classification: Mild, moderately severe, and severe. Outcomes and management in moderately severe group were also compared to mild and severe cases according to Atlanta 1992 and 2012 classification.

RESULTS

Fifty-three-point four percent of patients had edematous while 46.6 % were diagnosed with necrotic AP. The most common cause of AP was alcohol (42.7%) followed by alimentary (26.2%), biliary (26.2%) and idiopathic (4.9%). Under Atlanta 1992 classification 56 (54.4%) cases were classified as “mild” and 47 (45.6%) as “severe”. Using the revised classification (Atlanta 2012), the patient stratification was different: 49 (47.6%) mild, 27 (26.2%) moderately severe and 27 (26.2%) severe AP cases. The two severe groups (Atlanta 1992 and Revised Atlanta 2012) did not show statistically significant differences in clinical parameters, including ICU stay, need for interventional treatment, infected pancreatic necrosis or mortality rates. The moderately severe group of 27 patients (according to Atlanta 2012) had significantly better outcomes when compared to those 47 patients classified as severe form of AP (according to Atlanta 1992) with lower incidence of necrosis and sepsis, lower APACHE II (P = 0.002) and MODS (P = 0.001) scores, shorter ICU stay, decreased need for interventional and surgical treatment.

CONCLUSION

Study shows that Atlanta 2012 criteria are more accurate, reduce unnecessary treatments for patients with mild and moderate severe pancreatitis, potentially resulting in health costs savings.

Accuracy of circulating histones in predicting persistent organ failure and mortality in patients with acute pancreatitis

BACKGROUND

Early prediction of acute pancreatitis severity remains a challenge. Circulating levels of histones are raised early in mouse models and correlate with disease severity. It was hypothesized that circulating histones predict persistent organ failure in patients with acute pancreatitis.

METHODS

Consecutive patients with acute pancreatitis fulfilling inclusion criteria admitted to Royal Liverpool University Hospital were enrolled prospectively between June 2010 and March 2014. Blood samples were obtained within 48 h of abdominal pain onset and relevant clinical data during the hospital stay were collected. Healthy volunteers were enrolled as controls. The primary endpoint was occurrence of persistent organ failure. The predictive values of circulating histones, clinical scores and other biomarkers were determined.

RESULTS

Among 236 patients with acute pancreatitis, there were 156 (66·1 per cent), 57 (24·2 per cent) and 23 (9·7 per cent) with mild, moderate and severe disease respectively, according to the revised Atlanta classification. Forty-seven healthy volunteers were included. The area under the receiver operating characteristic (ROC) curve (AUC) for circulating histones in predicting persistent organ failure and mortality was 0·92 (95 per cent c.i. 0·85 to 0·99) and 0·96 (0·92 to 1·00) respectively; histones were at least as accurate as clinical scores or biochemical markers. For infected pancreatic necrosis and/or sepsis, the AUC was 0·78 (0·62 to 0·94). Histones did not predict or correlate with local pancreatic complications, but correlated negatively with leucocyte cell viability (r = -0·511, P = 0·001).

CONCLUSION

Quantitative assessment of circulating histones in plasma within 48 h of abdominal pain onset can predict persistent organ failure and mortality in patients with acute pancreatitis. Early death of immune cells may contribute to raised circulating histone levels in acute pancreatitis.

Elevated Serum Triglycerides in the Prognostic Assessment of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Hypertriglyceridemia has been positively associated with the risk of acute pancreatitis (AP), but whether increased triglyceride (TG) levels are associated with the severity of AP remains unknown. To this, a meta-analysis was conducted to assess the effect of elevated serum TG on the prognosis of AP.

METHODS

We searched PubMed, EMBASE, and the Cochrane library to identify all eligible studies (up to September 2016). We pooled the odds ratios (ORs) or standardized mean difference from individual studies using a random-effects model to investigate associations between levels of TG and the prognosis of AP.

RESULTS

A total of 15 studies were included in the meta-analysis, including a total of 1564 patients with triglyceride-related acute pancreatitis (TGAP) and 5721 patients with nontriglyceride-related acute pancreatitis (NTGAP). The occurrence of renal failure [OR=3.18; 95% confidence interval (CI): 1.92, 5.27; P<0.00001], respiratory failure (OR=2.88; 95% CI: 1.61, 5.13; P<0.0001), and shock (OR=3.78; 95% CI: 1.69, 8.44; P<0.0001) was statistically significantly higher in TGAP group than in NTGAP group. Furthermore, mortality (OR=1.90; 95% CI: 1.05, 3.45; P<0.01), systemic inflammatory response syndrome (OR=2.03; 95% CI: 1.49, 2.75; P<0.00001), and Acute Physiology and Chronic Health Evaluation (APACHE-II) scores (standardized mean difference=2.72; 95% CI: 1.00, 4.45; P<0.001) were also statistically significantly higher in TGAP group than in NTGAP group.

CONCLUSION

Elevated serum TGs are related to a worse prognosis of AP.

Immature granulocytes predict severe acute pancreatitis independently of systemic inflammatory response syndrome

Introduction

Early prediction of severity of acute pancreatitis (AP) by a simple parameter that positively correlates with the activation stage of the immune system would be very helpful because it could influence the management and improve the outcome. Tumor necrosis factor α (TNF-α) and interleukin-1 (IL-1) play a critical role in the pathogenesis systemic inflammatory response syndrome (SIRS) and severity of AP. One of the effects of IL-1 and TNF-α is an increase in the number of immature granulocytes (IGs) in the peripheral blood.

Aim

To assess whether the IGs% in plasma could be an independent marker of AP severity.

Material and methods

A cohort of 77 patients with AP were prospectively enrolled in the study. The IGs were measured from whole blood samples obtained from the first day of hospitalization using an automated analyser.

Results

We observed 44 (57%) patients with mild AP, 21 (27%) patients with moderate severe AP (SAP) and 12 (16%) patients with SAP. The cut-off value of IGs was 0.6%. The IGs > 0.6% had a sensitivity, specificity, and positive and negative predictive value of 100%, 96%, 85.7%, and 100%, respectively (area under the curve (AUC) = 0.98). On admission, SIRS was present in 25 (32%) patients. We found that in patients who fulfilled at least two criteria for SIRS, SAP could be predicted with 75% sensitivity and 75.4% specificity, positive predictive value 36%, negative predictive value 94.2%.

Conclusions

The IGs% as a routinely obtained marker appears to be a promising, independent biomarker and a better predictor of early prognosis in SAP than SIRS and white blood cell.

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.