Simple scoring system for the prediction of the prognosis of severe acute pancreatitis

Predicting the risk of early intensive care unit admission for patients hospitalized with acute pancreatitis using supervised machine learning

Background

Acute pancreatitis (AP) is a complex and life-threatening disease. Early recognition of factors predicting morbidity and mortality is crucial. We aimed to develop and validate a pragmatic model to predict the individualized risk of early intensive care unit (ICU) admission for patients with AP.

Methods

The 2019 Nationwide Readmission Database was used to identify patients hospitalized with a primary diagnosis of AP without ICU admission. A matched comparison cohort of AP patients with ICU admission within 7 days of hospitalization was identified from the National Inpatient Sample after 1:N propensity score matching. The least absolute shrinkage and selection operator (LASSO) regression was used to select predictors and develop an ICU acute pancreatitis risk (IAPR) score validated by 10-fold cross-validation.

Results

A total of 1513 patients hospitalized for AP were included. The median age was 50.0 years (interquartile range: 39.0-63.0). The three predictors that were selected included hypoxia (area under the curve [AUC] 0.78), acute kidney injury (AUC 0.72), and cardiac arrhythmia (AUC 0.61). These variables were used to develop a nomogram that displayed excellent discrimination (AUC 0.874) (bootstrap bias-corrected 95% confidence interval 0.824-0.876). There was no evidence of miscalibration (test statistic = 2.88; P = 0.09). For high-risk patients (total score >6 points), the sensitivity was 68.94% and the specificity was 92.66%.

Conclusions

This supervised machine learning-based model can help recognize high-risk AP hospitalizations. Clinicians may use the IAPR score to identify patients with AP at high risk of ICU admission within the first week of hospitalization.

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.

Ranson score to stratify severity in Acute Pancreatitis remains valid - Old is gold

Introduction: Acute pancreatitis (AP) is a common gastrointestinal disease with a wide spectrum of severity and morbidity. Developed in 1974, the Ranson score was the first scoring system to prognosticate AP. Over the past decades, while the Ranson score remains widely used, it was identified to have certain limitations, such as having low predictive power. It has also been criticized for its 48-hour requirement for computation of the final score, which has been argued to potentially delay management. With advancements in our understanding of AP, is the Ranson score still relevant as an effective prognostication system for AP?Areas covered: This review summarizes the available evidence comparing Ranson score with other conventional and novel scoring systems, in terms of prognostic accuracy, benefits, limitations and clinical applicability. It also evaluates the effectiveness of Ranson score with regard to the Revised Atlanta Classification.Expert opinion: The Ranson score consistently exhibits comparable prognostic accuracy to other newer scoring systems, and the 48-hour timeframe for computing the full Ranson score is an inherent strength, not a weakness. These aspects, coupled with relative ease of use, practicality and universality of the score, advocate for the continued relevance of the Ranson score in modern clinical practice.

Nomogram for predicting diabetes mellitus after the first attack of acute pancreatitis

BACKGROUND

Diabetes mellitus can occur after acute pancreatitis (AP), but there are currently no tools for evaluating the risk of developing diabetes after an attack of AP. The aim of the study was to develop a nomogram for prediction of new-onset diabetes mellitus after the first attack of AP.

PATIENTS AND METHODS

We enrolled 616 patients with first-attack AP. We collected and statistically analyzed demographic data (age, BMI, and duration of hospitalization) and laboratory data (glucose, low-density lipoprotein cholesterol, triglyceride, and cholesterol).

RESULTS

Univariate analysis suggested duration of hospitalization (P=0.0003), BMI (P=0.0059), cholesterol (P=0.0005), triglyceride (P=0.0005), hemoglobin (P=0.0229), and glucose (P<0.001) at admission were significantly associated with newly developed diabetes after the first-attack AP. Multivariate analysis showed that age [odds ratio (OR)=1.01; 95% confidence interval (CI): 1.00-1.03; P=0.045], BMI (OR=1.06; 95% CI: 1.01-1.12; P=0.018), glucose (OR=1.07; 95% CI: 1.02-1.12; P=0.008), triglyceride (OR=1.03; 95% CI: 1.00-1.06; P=0.035), and low-density lipoprotein-cholesterol (OR=1.18; 95% CI: 1.00-1.38; P=0.044) at admission were important predictors.

CONCLUSION

The nomogram is a potentially clinically useful tool for predicting new-onset diabetes, which is currently clinically unprecedented. This finding is not confined to the patients with severe AP but is also for patients who have recovered from mild AP. The nomogram must to be validated externally.

Early Hemoconcentration Is Associated With Increased Opioid Use in Hospitalized Patients With Acute Pancreatitis

OBJECTIVES

Opioids are commonly required for abdominal pain in hospitalized patients with acute pancreatitis (AP). The factors associated with increased opioid requirements are unknown.

METHODS

The medical records of adult inpatients with AP from 2006 to 2016 were reviewed. Patients with chronic pancreatitis, psychiatric comorbidities, intubation, chronic opioid, and illicit drug use were excluded. The total quantity of opioids required during the first 7 days of hospitalization was converted to oral morphine equivalents (OME), divided by the number of days opioids were required to obtain the mean OME per day(s) of treatment (MOME). Multiple regression analysis was performed to identify factors associated with MOME.

RESULTS

A total of 267 patients were included. The mean (standard deviation) age was 46.9 (13.9) years and 56% were males. The most common etiology was alcohol (55.4%). The mean (standard deviation) MOME was 59.1 (54.5) mg. Although age (P = 0.008), black race (P = 0.004), and first episode of AP (P = 0.049) were associated with a lower MOME, early hemoconcentration (hematocrit ≥44%) (P < 0.001) was associated with an increased MOME.

CONCLUSIONS

Early hemoconcentration is associated with an increased opioid requirement in hospitalized patients with AP. The impact of fluid therapy in these patients merits prospective study.

Are traditional scoring systems for severity stratification of acute pancreatitis sufficient?

BACKGROUNDS/AIMS

Ranson's score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP.

METHODS

We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed.

RESULTS

From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital.

CONCLUSIONS

RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.

Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis

OBJECTIVES

Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis.

METHODS

Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer's solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0-10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet.

RESULTS

The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21-4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02-0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01-0.49). No patients developed signs of volume overload.

CONCLUSIONS

Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis.

Prediction of acute pancreatitis in the earliest stages – role of biochemical parameters and histopathological changes

For many years, there has been a search for a set of biochemical parameters that could facilitate the assessment of severity, prognosis, and administration of early and appropriate treatment in acute pancreatitis. Administration of treatment within the first 48 hours since admission is associated with many problems of distinguishing patients with a mild form of acute pancreatitis (AP) from those with a severe form of acute pancreatitis. Study aim: To assess the relationship between the extent of change in the concentration of 10 selected biochemical indicators: amylase, lipase, total bilirubin, creatinine, uric acid, aspartate transaminase, alanine transaminase, glucose, magnesium, and iron and histopathological lesions in the pancreas within 2 and 6 hours since induction of AP. The selected time periods correspond to the first and the second day of the disease in people, respectively. Material and methods: The experiments were conducted in 110 male Wistar rats weighing from 250 to 300 g. Experimental animals were divided into three groups: Z – a group in which the ranges of the studied factors and histological structure were established; K – a group of animals operated on which were injected with 0.9% NaCl into the biliary-pancreatic duct; E – a group of animals operated on in which acute pancreatitis was induced by an injection of 5% sodium taurocholate into the biliary-pancreatic duct. Animals from the K and E groups were randomly assigned to one of five subgroups from which the material for biochemical and histological examinations was collected at 2 h and 6 h since the induction of AP. Whole pancreases were dissected for histological examinations, and the samples were dyed with hematoxylin and saturated alcoholic eosin solution. The degree of pancreatic lesions was assessed according to the Spormann score. Quantitative variables were characterized by arithmetic means, standard deviations, medians, minimum and maximum values, and 95% CIs. Results: In histological preparations from rats from the E group, after 2 hours, edematous lesions, neutrophilic infiltrations in the pancreatic parenchyma, together with single petechiae started to appear and were observed. After 6 hours, the lesions became more intense, and minor foci of coagulation necrosis and minor foci of purulent inflammation in the fatty tissue appeared. Within 2 hours, statistically significant differences in the amount of four markers: creatinine, ALT, amylase, and magnesium were observed. After six hours, statistically significant differences in the amount of two markers: AST and glucose were seen. The correlations between histological assessments according to the Spormann scale and biochemical indicators were investigated, and it was observed that within 2 hours the intensity of pancreatitis increased together with an increase in AST. In group K, within 6 hours, the intensity of inflammatory infiltration increased together with an increase in creatinine concentration (correlation coefficient 0.95; p=0.0138). In group E, in the period of 2 hours, lesion intensity in the form of inflammatory infiltration increased together with an increase in the AST level (correlation coefficient 0.90; p=0.0063) and an increase in the iron level (correlation coefficient 0.78; p=0.0399). In the same group and in the same period, an increase in the AST level (correlation coefficient 0.79; p=0.0343) was associated with an increase in lesion intensity in the form of ecchymoses. Inflammatory infiltration increased (correlation coefficient -0.87; p=0.0117) within 6 hours, whereas the creatinine level decreased. Interesting results were obtained with the use of regression analysis – forward stepwise regression. In the period of 2 hours, if the creatinine level increased by 1, the intensity of lesions in acute pancreatitis decreased by 9.02, according to the Spormann score, while the other variables remained at a stable level. However, if ALT level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.02, according to the Spormann score; and if the amylase level increased by 1, the intensity of lesions in acute pancreatitis increased by 0.01, according to the Spormann score, while the other variables remained at a stable level. Conclusions: Histopathological lesions occurred prior to changes in laboratory test results, whereas significant correlations with Spormann scores were seen in the case of changes in AST and creatinine levels. The study results confirm the fact that diagnostics in acute pancreatitis is very difficult and requires monitoring of many laboratory parameters.

Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points

Background and Aims. This study evaluated the prognostic accuracy of BUN for severe acute pancreatitis (SAP) and in-hospital mortality (IHM) in terms of the best timing for BUN measurement and the optimal BUN cutoff points. Methods. BUN determinants at the time of admission and 24 hrs after hospital admission were recorded and analyzed statistically. The ability of BUN in predicting the SAP and the occurrence of IHM were assessed using the area under the receiver-operating characteristic (ROC) curve. Results. For SAP, AUC of BUN at admission and 24 hrs after hospital admission was 0.75 and 0.80, respectively. For IHM in acute pancreatitis, it was 0.86 at admission and 0.84 after 24 hrs of hospital admission, respectively. The optimal cutoff point of BUN 24 hrs after hospital admission for SAP and at admission for IHM was 8.3 mmol/L and 13.3 mmol/L, respectively. Conclusion. BUN determination after 24 hrs of hospital admission has high accuracy for prediction of SAP while BUN at initial admission has high accuracy for prediction of IHM.

Pancreatic fluid collections: What is the ideal imaging technique?

Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walled-off necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging (MRI) performs better than computed tomography (CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis (seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis (solid debris delineation) and management (drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with ¹⁸F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.

Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis

OBJECTIVE

To develop a model for the early prediction of severe acute pancreatitis based on the revised Atlanta classification of acute pancreatitis.

METHODS

Clinical data of 1308 patients with acute pancreatitis (AP) were included in the retrospective study. A total of 603 patients who were admitted to the hospital within 36 hours of the onset of the disease were included at last according to the inclusion criteria. The clinical data were collected within 12 hours after admission. All the patients were classified as having mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) based on the revised Atlanta classification of acute pancreatitis. All the 603 patients were randomly divided into training group (402 cases) and test group (201 cases). Univariate and multiple regression analyses were used to identify the independent risk factors for the development of SAP in the training group. Then the prediction model was constructed using the decision tree method, and this model was applied to the test group to evaluate its validity.

RESULTS

The decision tree model was developed using creatinine, lactate dehydrogenase, and oxygenation index to predict SAP. The diagnostic sensitivity and specificity of SAP in the training group were 80.9% and 90.0%, respectively, and the sensitivity and specificity in the test group were 88.6% and 90.4%, respectively.

CONCLUSIONS

The decision tree model based on creatinine, lactate dehydrogenase, and oxygenation index is more likely to predict the occurrence of SAP.

Clinical update on fluid therapy and nutritional support in acute pancreatitis

BACKGROUND/OBJECTIVES

The aim of this focused review is to provide a valuable and updated source of information for clinical practice on fluid therapy (FT) and nutritional support in acute pancreatitis (AP).

METHODS

The review encompasses important new clinical information that has become available for understanding and offering these specific treatments since the 2013 publication of two guidelines, both the joint International Association of Pancreatology and American Pancreatic Association and the American College of Gastroenterology. The 2015 Revised Japanese Guideline is discussed selectively. To this end, the review is divided into 7 sections, including timing and cause of mortality; severity classification systems; predicting severity; response to treatment; nutritional support; fluid therapy and steps for further research.

CONCLUSIONS

In mild AP, begin oral feeding when nausea, vomiting and abdominal pain are improving. In (predicted) severe AP, feeding decisions should commence by 72 h, offering oral feeding if GI symptoms improve or enteral feeding if patients are symptomatic and/or intolerant to orals. All patients should be offered goal-directed FT during the first 6-12 h of presentation. Cautious FT is advised in those age >55 years or with preexisting organ failure or predictors of developing fluid sequestration.

Validation of the modified Ranson versus Glasgow score for pancreatitis in a Singaporean population

BACKGROUND

The characteristics of patients with acute pancreatitis in multi-ethnic Singapore differ from that of the populations used in formulating the modified Ranson and Glasgow scores. The use of these scoring systems has not previously been validated in the Singaporean setting. This study aims to validate and compare the prognostic use of the modified Ranson and Glasgow scores, and to determine the superiority of one score over the other in predicting the outcome for acute pancreatitis in the Singaporean population.

METHODS

This is a 3-year retrospective study of patients diagnosed with acute pancreatitis at our centre. Patients with chronic pancreatitis, acute on chronic pancreatitis, iatrogenic pancreatitis, pancreatic cancer as well as those with incomplete Ranson or Glasgow scores were excluded from the study. Case notes and computer records were reviewed for local complications of pancreatitis and organ failure. Receiver operator characteristic (ROC) curves of the Ranson and Glasgow scores were plotted for the prediction of severity and mortality.

RESULTS

Between January 2010 and December 2012, 230 cases were diagnosed with acute pancreatitis. A majority of the patients had mild pancreatitis (n = 194, 84.3%), and the overall 30-day mortality rate was 3.5% (n = 8). ROC of the Ranson and Glasgow scoring systems for mortality showed an area under curve (AUC) of 0.854 (P = 0.001) and 0.776 (P = 0.008), respectively. For severity, the AUC for the modified Ranson and Glasgow score was calculated to be 0.694 and 0.668, respectively.

CONCLUSIONS

The ROC curves of Ranson and Glasgow scores for mortality are comparable with that published in earlier studies. In a Singaporean population, the Ranson score is more accurate in the prediction of mortality. However, both scoring systems are poor predictors for severity of acute pancreatitis.

Urea

Urea is generated by the urea cycle enzymes, which are mainly in the liver but are also ubiquitously expressed at low levels in other tissues. The metabolic process is altered in several conditions such as by diets, hormones, and diseases. Urea is then eliminated through fluids, especially urine. Blood urea nitrogen (BUN) has been utilized to evaluate renal function for decades. New roles for urea in the urinary system, circulation system, respiratory system, digestive system, nervous system, etc., were reported lately, which suggests clinical significance of urea.

A prospective study of the Bedside Index for Severity in Acute Pancreatitis (BISAP) score in acute pancreatitis: an Indian perspective

INTRODUCTION

A simple and easily applicable system for stratifying patients with acute pancreatitis is lacking. The aim of our study was to evaluate the ability of BISAP score to predict mortality in acute pancreatitis patients from our institution and to predict which patients are at risk for development of organ failure, persistent organ failure and pancreatic necrosis.

METHODS

All patients with acute pancreatitis were included in the study. BISAP score was calculated within 24 h of admission. A Contrast CT was used to differentiate interstitial from necrotizing pancreatitis within seven days of hospitalization whereas Marshall Scoring System was used to characterize organ failure.

RESULTS

Among 246 patients M:F = 153:93, most common aetiology among men was alcoholism and among women was gallstone disease. 207 patients had no organ failure and remaining 39 developed organ failure. 17 patients had persistent organ failure, 16 of those with BISAP score ≥3. 13 patients in our study died, out of which 12 patients had BISAP score ≥3. We also found that a BISAP score of ≥3 had a sensitivity of 92%, specificity of 76%, a positive predictive value of 17%, and a negative predictive value of 99% for mortality.

DISCUSSION

The BISAP score is a simple and accurate method for the early identification of patients at increased risk for in hospital mortality and morbidity.

Risk factors for pancreatic infection in patients with severe acute pancreatitis: an analysis of 163 cases

OBJECTIVE

We aimed to identify the risk factors for predicting pancreatic infection in patients with severe acute pancreatitis (SAP).

METHODS

In all, 163 patients with SAP were included and divided into two groups based on the presence or absence of pancreatic infection. Their demographic and clinical characteristics, laboratory examination results, complications and treatment modalities were collected from their medical records. Variables were initially screened by univariate analysis and those with statistical significance were then filtered by multivariate analysis to determine the independent risk factors for pancreatic infection in SAP.

RESULTS

Patients having SAP with pancreatic infection had a lower partial pressure of arterial carbon dioxide (PaCO2 ), peripheral white blood cell count and alkaline phosphatase levels, together with a higher computed tomography severity index (CTSI) than those without pancreatic infection, while their lactate dehydrogenase (LDH) levels and blood urea nitrogen were much higher. Pancreatic infection was also more common in patients receiving late fluid resuscitation than in those receiving early fluid resuscitation. Multivariate analyses revealed that increased LDH level, high CTSI, delayed fluid resuscitation and hypoxemia were independent risk factors for pancreatic infection in SAP. The sensitivity, specificity, positive and negative predictive values for a model combining the parameters in predicting pancreatic infection were 84%, 97%, 88% and 96%, respectively, with a cut-off value of 0.393, and the area under the receiver operating characteristic curve was 0.923.

CONCLUSION

Increased LDH, high CTSI, delayed fluid resuscitation and hypoxemia are independent risk factors for predicting pancreatic infection in patients with SAP.

A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis

OBJECTIVES

There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS).

DESIGN/SETTING

Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital.

PARTICIPANTS

Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11).

INTERVENTION

The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations.

RESULTS

The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P<0.0001) and intravenous fluids >6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001).

CONCLUSIONS

The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission. World J Surg. 2013;37:318-332. [PMID: 23052814 PMCID: PMC3553416 DOI: 10.1007/s00268-012-1821-8]

Background

Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality.

Methods

A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS.

Result

Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052–1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012–1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000–1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients’ age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548–0.661).

Conclusions

Patients’ age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

Time period from onset of pain to hospital admission and patients' awareness in acute pancreatitis

OBJECTIVES

This study aimed to explore the period between onset of pain and hospital-admission (pain-to-admission time) in patients with acute pancreatitis (AP), to investigate the prognostic value and associated factors of this time, and to ascertain the knowledge about the pancreas in these patients.

METHODS

An analysis of a prospective multicenter study was done, which included 188 patients with AP.

RESULTS

Median pain-to-admission time was 27 hours (interquartile range, 6.0-72.0). Median pain-to-admission time was significantly shorter in intensive care unit (ICU) patients (10 hours) compared to non-ICU patients (36 hours) (P = 0.045). Short pain-to-admission time was associated with high pain level. Median pain level (0, no pain; 10, maximal pain) was 8.0 (interquartile range, 7.0-10.0). Older age correlated with lower pain level (r = -0.26; P = 0.002). Multiple logistic regression analysis including the admission values for serum lipase and C-reactive protein and the corresponding interactions to the pain-to-admission time showed substantial discriminative ability regarding ICU admission (concordance index, 0.706; P = 0.006). 86% (112/130) knew that they have a pancreas, 72% (81/112) of these patients knew that AP exists, and 56% (45/81) recognized that AP is potentially fatal.

CONCLUSIONS

Knowledge about AP in hospitalized AP patients is poor. Serum lipase and C-reactive protein in dependency of the pain-to-admission time might be a suitable predictor for severity of AP.

Acute pancreatitis scoring systems

Acute pancreatitis (AP) is a common acute abdominal disease that can be divided into mild acute pancreatitis and severe acute pancreatitis (SAP). SAP accounts for 20%-30% of all AP cases, progresses rapidly and is associated with a high mortality rate. Early identification, diagnosis and treatment of SAP are important for improving the prognosis. This article will introduce common AP scoring systems and describe the characteristics of each system.

An assessment of the severity of interstitial pancreatitis

BACKGROUND & AIMS

There is limited information on the incidence of and factors associated with severe disease among patients with interstitial pancreatitis (IP). We evaluated a large cohort of patients with IP and compared data with those from patients with extrapancreatic necrosis (EXPN).

METHODS

We evaluated 149 consecutive patients with IP admitted over a 2.5-year period. Transferred patients were excluded. We collected data on age, Charlson comorbidity score (CCI), measures of severity on admission or within 24 hours (Acute Physiology and Chronic Health Evaluation II, bedside index for severity of acute pancreatitis scores), persistent (>48 h) systemic inflammatory response syndrome, persistent organ failure, need for intensive care unit, length of hospital stay (in days), and mortality. We also analyzed levels of severity among those with IP and EXPN. Statistical analysis was performed using SAS version 9.1 (Cary, NC).

RESULTS

Among the patients with IP, the median CCI score was 1, the median Acute Physiology and Chronic Health Evaluation II score was 7, and the median bedside index for severity of acute pancreatitis score was 1. In addition, the median length of hospital stay was only 4 days; only 1% had persistent organ failure and only 1% to 2% required intervention. The mortality rate of IP was 3%; it was associated significantly with comorbidity (the median CCI scores of nonsurvivors and survivors was 4 and 1, respectively, P = .003). Patients with EXPN had greater levels of disease severity, compared with patients with IP.

CONCLUSIONS

IP is severe in only 1% to 3% of patients; mortality of IP is associated strongly with comorbidity. EXPN is more frequently severe than IP; EXPN must be distinguished from IP in clinical studies.

Prediction of severe acute pancreatitis using classification and regression tree analysis

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of severe acute pancreatitis at admission to hospital using artificial neural networks

BACKGROUND/AIMS

Artificial neural networks (ANNs) are non-linear pattern recognition techniques, which can be used as a tool in medical decision-making. The aim of this study was to construct and validate an ANN model for early prediction of the severity of acute pancreatitis (AP).

METHODS

Patients treated for AP from 2002 to 2005 (n = 139) and from 2007 to 2009 (n = 69) were analyzed to develop and validate the ANN model. Severe AP was defined according to the Atlanta criteria.

RESULTS

ANNs selected 6 of 23 potential risk variables as relevant for severity prediction, including duration of pain until arrival at the emergency department, creatinine, hemoglobin, alanine aminotransferase, heart rate, and white blood cell count. The discriminatory power for prediction of progression to a severe course, determined from the area under the receiver-operating characteristic curve, was 0.92 for the ANN model, 0.84 for the logistic regression model (p = 0.030), and 0.63 for the APACHE II score (p < 0.001). The numbers of correctly classified patients for a sensitivity of 50 and 75% were significantly higher for the ANN model than for logistic regression (p = 0.002) and APACHE II (p < 0.001).

CONCLUSION

The ANN model identified 6 risk variables available at the time of admission, including duration of pain, a finding not being presented as a risk factor before. The severity classification developed proved to be superior to APACHE II. and IAP.

Acute pancreatitis

Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.

Use of antibiotics in severe acute pancreatitis

Infectious complications in severe acute pancreatitis are an important problem and determine outcome in patients who survived the first inflammatory hit of the disease. Timely diagnosis of infected pancreatic necrosis is often challenging, but should not delay adequate treatment, which consists of source control and antibiotic treatment. Prophylactic antibiotics are not effective in reducing the incidence of (peri)pancreatic infection in patients with severe acute pancreatitis (or necrotizing pancreatitis). The only rational indication for antibiotics at this moment is documented infection. The spectrum of empiric antibiotics should cover both Gram-negative, Gram-positive and anaerobic microorganisms (also keeping in mind exposure to nosocomial microorganisms), and local ecology should be taken into account. Fungal infections are often present, and antifungal coverage should be considered, especially if multiple risk factors for invasive candidiasis are present. Currently, no tools are available to guide antimicrobial treatment.

Simplified Early Predictors of Severe Acute Pancreatitis: A Prospective Study

Background

To propose simple tests for the prediction of severe acute pancreatitis (SAP), which are accurate and could be performed at emergency departments and outpatient clinics.

Methods

A prospective study was performed on 149 patients admitted with acute pancreatitis. Body mass index (BMI), plain chest radiograph, blood biochemical data were obtained at the time of admission; white cell, lymphocyte and platelet counts, hematocrit level, prothrombin time, PaO₂, creatinine, calcium, blood sugar, total protein, aspartate aminotransferase, total bilirubin, amylase, lipase and C-reaction protein were determined. Patients were graded into severe and mild acute pancreatitis based on CT Balthazar grading system.

Results

Twenty-seven patients were diagnosed to have SAP and 122 patients considered mild acute pancreatitis. Comparing parameters between both groups; significant factors (P < 0.05) were blood sugar level, haematocrit level, BMI and presence of pleural effusion in chest X-ray. The hematocrit at admission and at approximately 24 hours was significantly higher among patients with SAP. Twenty-two of 27 cases of severe disease and only 10 of 122 cases of mild acute pancreatitis diagnosed to have pleural effusion (P < 0.001).

Conclusion

BMI, blood glucose ≥ 190 mg/dL, hematocrit level ≥ 43 % and pleural effusion detected by plain chest radiograph are simple tests and provide significant predictive power for clinical decision-making.

[Evaluation of severity in acute pancreatitis]

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

Prediction of mortality in acute pancreatitis: a systematic review of the published evidence

OBJECTIVE

In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis.

SUMMARY BACKGROUND DATA

Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality.

METHODS

All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded.

RESULTS

58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power.

CONCLUSIONS

Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.

The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. Curr Gastroenterol Rep. 2009;11:97-103. [PMID: 19281696 DOI: 10.1007/s11894-009-0016-4]

Acute pancreatitis continues to be a diagnostic and therapeutic challenge for physicians and surgeons. It ranks third in the list of hospital discharges for gastro-intestinal diseases. In most patients the cause is either gallstones or alcoholism. The overall mortality is less than 5%, but severe acute pancreatitis leads to prolonged hospitalization and much higher mortality. There are important differences in disease susceptibility and case fatality rates: the incidence is higher in blacks than in whites, and mortality is higher in older patients than in younger patients. Reports from various countries reveal that the frequency of acute pancreatitis is increasing, perhaps in relation to rising obesity rates, which would increase the likelihood of gallstone pancreatitis. Conversely, mortality rates for acute pancreatitis are declining in many, but not all, reports.

Acute pancreatitis: radiologic scores in predicting severity and outcome

Acute pancreatitis (AP) is a common inflammatory disease which can be mild and self-limiting without complications or severe with prolonged hospitalization, high morbidity, and high mortality. Different radiological scoring systems to predict severity and outcome in AP have been developed since the early 1990s. In the meantime, new insights in the pathophysiology of AP and consequently, therapeutic management of these patients have been introduced. The purpose of this review is therefore (1) to describe the current terminology and new concepts in the pathophysiology, (2) to outline the long existing and newly developed radiological scoring systems in prediction of severity and outcome with their respective advantages and limitations, and (3) to define the role of radiological prognostic scoring systems in the new environment of perception of the last decade. Risk stratification in AP requires scoring systems that can be calculated early in the course of disease which allows time for intervention. For that reason, scoring systems based on necrosis are not useful in severity prediction. The recent developed radiological scoring systems based on signs of systemic inflammatory response syndrome and organ dysfunction are promising in prediction of severity early after onset of AP.

A simple prognostic score for risk assessment in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common disease that poses potential serious problems. Its clinical course is often unpredictable. Identification of high risk patients enables early appropriate treatment.

METHODS

We conducted a prospective study to develop a new prognostic method that can objectively and easily grade the severity of AP within the first 72 h of admission. The prediction rule was based on clinical and analytical parameters in 308 patients admitted in a community-based hospital. We validated the score in 193 additional patients in the same hospital.

RESULTS

Independent prognostic factors related to poor prognosis were age >65 years, leucocytes >13,000/mm(3), albumin <2.5 mg/dL, calcium <8.5 mg/dL and reactive C protein >150 mg/dL. We assigned points to each of the independent factors for complicated AP in proportion to the regression coefficients. We defined three different risk groups according to the points obtained in the prediction rule. Low risk, 0 points (18% patients, 0% risk), moderate, 1-3 points (56% patients, 19% risk) and high, 4-6 points (26% patients, 73% risk). The sensitivity of this formula was 90% with specificity of 63%. The positive and negative predictive values were 50% and 94% respectively.

CONCLUSIONS

Our simple prediction rule is an additional tool that may help physicians stratifying the severity of AP. Patients with high risk for complicated AP should be kept under close surveillance whereas low risk patients would not need special monitoring.

A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis

OBJECTIVES

Our aim was to prospectively evaluate the ability of the bedside index for severity in acute pancreatitis (BISAP) score to predict mortality as well as intermediate markers of severity in a tertiary center.

METHODS

The BISAP score was evaluated among 397 consecutive cases of acute pancreatitis admitted to our institution between June 2005 and December 2007. BISAP scores were calculated on all cases using data within 24 h of presentation. The ability of the BISAP score to predict mortality was evaluated using trend and discrimination analysis. The optimal cutoff score for mortality from the receiver operating curve was used to evaluate the development of organ failure, persistent organ failure, and pancreatic necrosis.

RESULTS

Among 397 cases, there were 14 (3.5%) deaths. There was a statistically significant trend for increasing mortality (P < 0.0001) with increasing BISAP score. The area under the receiver operating curve for mortality by BISAP score in the prospective cohort was 0.82 (95% confidence interval: 0.70, 0.95), which was similar to that of the previously published validation cohort. A BISAP score >or=3 was associated with an increased risk of developing organ failure (odds ratio=7.4, 95% confidence interval: 2.8, 19.5), persistent organ failure (odds ratio=12.7, 95% confidence interval: 4.7, 33.9), and pancreatic necrosis (odds ratio=3.8, 95% confidence interval: 1.8, 8.5).

CONCLUSIONS

The BISAP score represents a simple way to identify patients at risk of increased mortality and the development of intermediate markers of severity within 24 h of presentation. This risk stratification capability can be utilized to improve clinical care and facilitate enrollment in clinical trials.

Risk assessment in acute pancreatitis

BACKGROUND

Acute pancreatitis has a variable natural history and in a proportion of patients is associated with severe complications and a significant risk of death. The various tools available for risk assessment in acute pancreatitis are reviewed.

METHODS

Relevant medical literature from PubMed, Ovid, Embase, Web of Science and The Cochrane Library websites to May 2008 was reviewed.

RESULTS AND CONCLUSION

Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis in the first 48-72 h. Biochemical and immunological markers, imaging modalities and novel predictive models may help identify patients at high risk of complications or death. Recently, there has been a recognition of the importance of the systemic inflammatory response syndrome and organ dysfunction.

Prediction of early death in severe acute pancreatitis

BACKGROUND

In severe acute pancreatitis (SAP), it is clinically important at the time of admission to predict the likelihood of early death. This investigation aimed to clarify the factors predicting early death in SAP.

METHODS

Early death was defined as death within 10 days after disease onset. Prediction factors for early death were evaluated from data obtained on admission from 93 patients with SAP, and the characteristics of patients who died early were analyzed.

RESULTS

Between the early-death and early-survival groups, significant factors were base excess (BE), serum creatinine (Cr), blood sugar, serum glutamate oxaloacetic transaminase, and serum calcium. Multivariate analysis revealed that BE was an independent prediction factor for early death. The early-death rate in patients with BE < -5.5 mEq/l and Cr >or= 3.0 mg/dl was 31% and 36%, respectively. The combination of BE and Cr raised the positive predictive value to 50%, and was equally able to predict early death as the Japanese Severity Score (JSS), which was the most useful of the three conventional scoring systems used. All early-death patients had pancreatic necrosis, and their JSS was >or= 15 (stage 4). Characteristically, early-death patients had lactate dehydrogenase (LDH)>1300 IU/l, or they had serious preexisting comorbidities.

CONCLUSIONS

As a single parameter, BE was most useful for predicting early death. The combination of BE and Cr could predict early death as well as the JSS. An extreme rise of LDH and serious preexisting comorbidity may also be risk factors for early death.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.

Chronic pain reconsidered

Chronic pain has been traditionally defined by pain duration, but this approach has limited empirical support and does not account for chronic pain's multi-dimensionality. This study compared duration-based and prospective approaches to defining chronic pain in terms of their ability to predict future pain course and outcomes for primary care patients with three common pain conditions: back pain (n=971), headache (n=1078), or orofacial pain (n=455). At baseline, their chronic pain was classified retrospectively based on Pain Days in the prior six months and prospectively with a prognostic Risk Score identifying patients with "possible" or "probable" chronic pain. The 0-28 Risk Score was based on pain intensity, pain-related activity limitations, depressive symptoms, number of pain sites, and Pain Days. Pain and behavioral outcomes were assessed at six-month follow-up, and long-term opioid use was assessed two to five years after baseline. Risk Score consistently predicted clinically significant pain at six months better than did Pain Days alone (area under the curve of 0.74-0.78 for Risk Score vs. 0.63-0.73 for Pain Days). Risk Score was a stronger predictor of future SF-36 Physical Function, pain-related worry, unemployment, and long-term opioid use than Pain Days alone. Thus, for these three common pain conditions, a prognostic Risk Score had better predictive validity for pain outcomes than did pain duration alone. However, chronic pain appears to be a continuum rather than a distinct class, because long-term pain outcomes are highly variable and inherently uncertain.

Treatment strategy against infection: clinical outcome of continuous regional arterial infusion, enteral nutrition, and surgery in severe acute pancreatitis

BACKGROUND

In severe acute pancreatitis (SAP), infectious complications are the main contributors to high mortality. Since 1995, we have performed continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) as prevention therapies against infection. When infected pancreatic necrosis was proven, surgical intervention was adapted. The aim of this study was to investigate the clinical outcome of these treatments.

METHODS

We examined the relationship between the historical change of treatment strategy and clinical outcome. We divided 84 patients with acute necrotizing pancreatitis into two groups, CRAI (-) and CRAI (+), and compared the outcome. We divided 145 patients with SAP into two groups, EN (-) and EN (+), and compared the outcome. We also analyzed the outcome of surgical treatment.

RESULTS

In the CRAI (+) group, the incidence of infection, the frequency of surgery, and the mortality rate were lower than those in CRAI (-) group: 34% versus 51%, 27% versus 63% (P < 0.05), and 37% versus 54%, respectively. In the EN (+) group, the frequency of surgery and the mortality rate were lower than those in the EN (-) group: 23% versus 32% and 19% versus 35% (P < 0.05), respectively. These improvement effects were manifest in stage 3 (9 < or = Japanese Severity Score < or = 14). Treatment outcome of necrosectomy for infected pancreatic necrosis was still poor. Bleeding and abscess-gut fistula were postoperative life-threatening complications.

CONCLUSIONS

CRAI and EN may improve the clinical outcome of SAP, reducing infection and averting pancreatic surgery.