Serial computed tomography is rarely necessary in patients with acute pancreatitis: a prospective study in 102 patients

[Overview of relevant clinical recommendations from the new S3 guidelines on acute and chronic pancreatitis]

Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified.

Prediction of Necrotizing Pancreatitis on Early CT Based on the Revised Atlanta Classification

Purpose

To investigate the clinical and CT features at admission to predict the progression to necrotizing pancreatitis (NP) in patients initially diagnosed with interstitial edematous pancreatitis (IEP).

Materials and Methods

Patients with IEP who underwent contrast-enhanced CT at admission and follow-up CT (< 14 days) were included (n = 178). Two radiologists performed a consensus review of follow-up CT scans and diagnosed the type of acute pancreatitis as IEP or NP. Laboratory findings at admission were recorded. Clinical, CT, and laboratory findings were compared between the IEP-IEP group and IEP-NP group using the chi-square test and the t-test. Multivariate analysis was also performed.

Results

There were 112 and 66 patients in the IEP-IEP and the IEP-NP groups, respectively. The proportion of patients with alcohol etiology was significantly larger in the IEP-NP group. Among the CT findings, the presence of peripancreatic fluid and heterogeneous parenchymal enhancement were more frequently observed in the IEP-NP group. Among the laboratory variables, serum C-reactive protein levels and white blood cell counts were significantly higher in the IEP-NP group. Multivariate analysis revealed that the presence of peripancreatic fluid and heterogeneous parenchymal enhancement were significant findings distinguishing the two groups.

Conclusion

CT findings, such as the presence of peripancreatic fluid and heterogeneous pancreatic parenchymal enhancement, may be helpful in predicting the progression to NP in patients initially diagnosed with IEP.

Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit

Background

While acute pancreatitis (AP) resolves spontaneously with supportive treatment in most patients, it may be life-threatening. Predicting the disease severity at onset dictates the management strategy. We aimed to define the patients with mild pancreatitis who may be considered for outpatient management with significant cost-savings.

Materials and Methods

This prospective observational study included 180 patients with mild AP according to the harmless acute pancreatitis score (HAPS) and Imrie score. The relationships of biochemical parameters with the changes in the Balthazar score and clinical course were examined.

Results

The study included 180 patients (111 females, 69 males; mean age: 53.9 ± 17.2 years; range: 17-92 years). The etiology was biliary in 118 (65%) patients and remained undetermined in 38 (21.1%) patients. Computed tomography (CT) performed within the first 12 h revealed mild and moderate AP in 159 (88.3%) and 21 (11.7%) patients, respectively. CT repeated at 72 h revealed mild, moderate, and severe AP in 155 (86.1%), 24 (13.3%), and 1 (0.6%) patients, respectively. Comparisons between stages A + B + C and D + E showed significant differences in the amylase levels on day 1 and 3, and in C-reactive protein on day 3. Also, in stage D and E disease, narcotic analgesic intake, oral intake onset time, and pain were significantly higher.

Conclusion

There were no significant changes in the CT findings of patients with mild AP at 12 and 72 h. Most patients (n = 179; 99.4%) recovered uneventfully. Patients with mild pancreatitis according to the HAPS and Imrie scores can be considered for outpatient management. The recovery is longer in stage D and E disease.

Usefulness of scheduled follow-up CT in discharged patients with acute pancreatitis

BACKGROUND AND AIM

Follow-up computed tomography (CT) in patients with acute pancreatitis has been advocated but rarely studied. The aim of this study was to determine whether follow-up CT for acute pancreatitis might be helpful in establishing the prognosis or complications, and in determining a selected subgroup of patients for whom computed tomography could be beneficial.

METHODS

Between January 2010 and December 2012, patients with acute pancreatitis who underwent follow-up CT in the outpatient department between one and three months after discharge were retrospectively enrolled. Events discovered on follow-up CT were defined as newly developed or increased pancreatic collection such as pseudocyst or walled off necrosis, and diagnosis of pancreatic cancer.

RESULTS

Ultimately, 106 asymptomatic patients were enrolled (mean age 50.24 ± 16, 74.5% male, 31.1% moderately severe and severe acute pancreatitis). The median duration of follow-up CT was 69 (31-90) days. On follow-up CT, 23 patients showed events (2 pancreatic cancer, 21 increasing or developed pancreatic collections). In multivariate analysis, the predictive factors for events on follow-up CT were CTSI ≥3 (OR 4.46, CI 1.08-18.43, p = 0.039) and BISAP ≥ 2 (OR 4.83, CI 1.08-21.55, p = 0.039).

CONCLUSIONS

Follow-up CT within three months after discharge may be helpful for acute pancreatitis patients with CTSI ≥ 3 points or BISAP score ≥ 2 points.

Modified Computed Tomography Severity Index for Evaluation of Acute Pancreatitis and its Correlation with Clinical Outcome: A Tertiary Care Hospital Based Observational Study

BACKGROUND

Acute Pancreatitis is a very common condition leading to the emergency visits in both developed and developing countries. Computed Tomography plays a pivotal role in the diagnosis and subsequent management of pancreatitis. The modified CT severity index includes a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extra pancreatic complications.

AIM

To study role of modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome.

MATERIALS AND METHODS

This was a hospital based prospective correlative study done on patients of all age groups referred to the Department of Radio diagnosis from the various indoor and outdoor departments of the hospital, with clinical/Laboratory/ultrasonography findings suggestive of acute pancreatitis. The severity of pancreatitis was scored using Modified CT severity index & CT severity index and classified into mild, moderate and severe categories. Total of 50 patients of acute pancreatitis presenting to the emergency department of our hospital were included in the study. Clinical outcome parameters for correlation collected from respective referral departments included, the length of hospital stay (in days), need for surgical intervention, need for percutaneous intervention (aspiration and drainage), evidence of infection in any organ system (combination of a fever > 100°F and elevated WBC >15,000/ mm(3)), evidence of organ failure (PaO2 < 60 mm Hg or need of ventilation, systolic BP of < 90 mm Hg, serum creatinine of >300μmoles/L or urine output of < 500 ml / 24 h) and death.

RESULTS

The age of the patients in the study group was in the range of 17 to 80 years. Maximum patients were in the age group 40-50 years (42.0%). The mean age was 42.32 years. Out of 50 cases, 33 (66%) were male and 17 (34%) were females with a male to female ratio of 2:1. Cholelithiasis was found to be most common aetiological factor for acute pancreatitis in 40% cases. Alcoholic pancreatitis was seen in 36% of cases. Together cholelithiasis and alcoholism accounted for 76% of cases. Pleural effusion was the most common extra-pancreatic complication, 28 patients (56%), followed by ascites. Majority of patients were categorized as severe pancreatitis (44%). 38% patients were grouped into moderate pancreatitis and 18% were categorized in mild pancreatitis. The outcome parameters in terms of length of hospital stay, need of intervention, development of infection, and development of organ failure were more in patients with higher modified CT severity index.

CONCLUSION

In conclusion CECT was found to be an excellent imaging modality for diagnosis, establishing the extent of disease process and in grading its severity. The Modified CT Severity Index is a simpler scoring tool and more accurate than the Balthazar CT Severity Index. In this study, it had a stronger statistical correlation with the clinical outcome, be it the length of hospital stay, development of infection, occurrence of organ failure and overall mortality. It could also predict the need for interventional procedures.

Treating acute pancreatitis: what's new?

The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study

BACKGROUND

Early computed tomography (CT) (within 4 full days after symptom onset) may be performed to distinguish acute pancreatitis (AP) from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed practice and yield of early CT in patients with an established clinical diagnosis of AP in a Dutch cohort (EARL study).

METHODS

Multicenter observational study. Etiology, disease course, CT timing, Balthazar CT score, and clinical management were evaluated.

RESULTS

First documented hospital admissions of 166 patients were analyzed. Etiology was biliary (42.8%), unknown (20.5%), alcoholic (18.1%), post-endoscopic retrograde cholangiopancreatography (11.4%), and miscellaneous (7.2%). In 89.2% (148/166), the disease course was mild. Out of 18 patients with severe AP, 11 eventually developed (peri)pancreatic necrosis. At least one CT (range 1-12) was performed in 47% (78/166) of all patients and in 62.8% (49/78) it was acquired within 4 full days after symptom onset. Practice, timing, and Balthazar CT score of early CTs were not significantly different between mild and severe AP. None of the early CTs showed necrosis and no alternative diagnoses were established. In 89.8% (44/49), clinical management was not altered after early CT. In 10.2% (5/49), prophylactic antibiotics were started, but in absence of necrosis.

CONCLUSIONS

A CT scan was frequently acquired early in the course of AP, but its yield was low and had no implications with regard to clinical management. It seems prudent that clinicians should be more restrictive in the use of early CT, in particular in mild AP, to prevent unnecessary radiation exposure and to save costs.

[Acute pancreatitis]

Acute pancreatitis is potentially fatal. It can be diagnosed based on present history, clinical appearance, and typical findings from laboratory and radiologic investigations. All patients must be admitted to hospital, as the disease course cannot be predicted at initial presentation. Increasing severity demands increasingly individualized therapy. The most important interventions are fast fluid resuscitation and analgesic therapy with opioids. Therapeutic agents specific to pancreatitis have failed to show any advantages so far. The roles of antibiotic therapy and nutritional support in the therapeutic regimen have been profoundly reassessed during recent years. Surgery and endoscopic interventions may be necessary and beneficial in carefully selected patients. In this review we summarize clinically relevant issues of acute pancreatitis.

USEFULNESS OF INFRARED SPECTROSCOPY IN DIAGNOSIS OF ACUTE PANCREATITIS

BACKGROUND

The lack of a gold standard for the diagnosis of acute pancreatitis remains a problem. Our aim was to evaluate whether infrared spectroscopy of serum can establish the diagnosis of acute pancreatitis.

METHODS

Sixty-four patients with acute pancreatitis, 112 patients with non-pancreatic acute abdomen and 40 healthy subjects were studied. In addition to serum infrared spectral analysis, serum concentrations of amylase and lipase were measured on admission.

RESULTS

Infrared spectroscopy based on serum absorption patterns in the range 800-1000 nm successfully distinguished acute pancreatitis from acute abdominal disorders of extrapancreatic origin and from control specimens. The sensitivity, specificity and positive and negative predictive values of infrared spectroscopy on admission were 91, 91, 85, and 94%, respectively. Within 24 h of onset of symptoms, infrared spectroscopy, lipase and amylase showed similar areas under the ROC curves for infrared spectra of serum (0.93), lipase (0.96) and amylase (0.91).

CONCLUSIONS

The successful classification of infrared spectra in patients with acute pancreatitis implies that the pathophysiology of disease alters the composition of the specimen in a characteristic fashion--in this case the serum make-up reflects the presence of acute pancreatitis.

Late development of pancreas necrosis during acute pancreatitis: an underestimated phenomenon associated with high morbidity and mortality

OBJECTIVE

The purpose of this study is to assess the prognostic significance of late parenchymal pancreas necrosis as observed on serial contrast-enhanced computed tomographic (CT) scan.

METHODS

Eighty-four patients with acute necrotizing pancreatitis were included. All initial CT scans were examined on complete contrast enhancement of the pancreas parenchyma (viable pancreas) or incomplete enhancement indicating parenchymal necrosis of the pancreas (PN). Secondly, all serial CT scans were evaluated to investigate whether late PN occurred in the group with a viable pancreas on initial CT scan. Characteristics of this group were evaluated.

RESULTS

Thirteen patients showed signs of PN on initial CT scan. Late necrosis occurred in 5 patients. The average hospital stay in this subgroup was 46.7 days; complication rate, 100%; and mortality, 40%. A significant difference in hospital stay (average of 45.1 days vs 24.3 days; P = 0.003), complication rate (72% vs 33%; P = 0.006), and mortality (28% vs 6%; P = 0.019) was found when the group with eventual PN was compared with the group with no signs of PN (on initial and serial CT).

CONCLUSIONS

This study shows a significant increase in hospital stay, complication rate, and mortality when eventual PN is shown on CT scan. Patients with late PN especially have a poor prognosis.

The spectrum of valproic acid-associated pancreatitis

OBJECTIVE

Our goal was to characterize valproic acid-associated pancreatitis in children.

PATIENTS AND METHODS

The charts of all patients with pancreatitis (diagnosed by using strict criteria) associated with valproic acid during a 10-year period were reviewed. Clinical and laboratory results were abstracted.

RESULTS

Twenty-two patients with valproic acid-associated pancreatitis were seen during the study period. Symptoms were similar to those of patients with pancreatitis from other etiologies and included abdominal pain/tenderness (83%), vomiting/retching (74%), abdominal distention (30%), and fever/chills (26%). Valproic acid levels were in the therapeutic range in all but 1 patient. The mean duration of therapy before the onset of pancreatitis was 32 months. The serum lipase level was >3 times the reference value in all patients, but the serum amylase level was not significantly elevated in 31% of the patients tested. Imaging studies altered clinical management in only 1 patient. The length of stay was generally brief (mean: 8 days). Two patients died. Of the 5 patients who were rechallenged, 4 had relapses.

CONCLUSIONS

Valproic acid-associated pancreatitis does not depend on valproic acid serum level and may occur any time after the onset of therapy. The serum lipase level is more sensitive than the serum amylase level and should be obtained when pancreatitis is suspected. Early imaging studies did not change clinical management. Rechallenge with valproic acid is dangerous and should be avoided.

Acute interstitial edematous pancreatitis: Findings on non-enhanced MR imaging

AIM: To study the appearances of acute interstitial edematous pancreatitis (IEP) on non-enhanced MR imaging.

METHODS: A total of 53 patients with IEP diagnosed by clinical features and laboratory findings were underwent MR imaging. MR imaging sequences included fast spoiled gradient echo (FSPGR) fat saturation axial T1-weighted imaging, gradient echo T1-weighted (in phase), single shot fast spin echo (SSFSE) T2-weighted, respiratory triggered (R-T) T2-weighted with fat saturation, and MR cholangiopancreatography. Using the MR severity score index, pancreatitis was graded as mild (0-2 points), moderate (3-6 points) and severe (7-10 points).

RESULTS: Among the 53 patients, IEP was graded as mild in 37 patients and as moderate in 16 patients. Forty-seven of 53 (89%) patients had at least one abnormality on MR images. Pancreas was hypointense relative to liver on FSPGR T1-weighted images in 18.9% of patients, and hyperintense in 25% and 30% on SSFSE T2-weighted and R-T T2-weighted images, respectively. The prevalences of the findings of IEP on R-T T2-weighted images were, respectively, 85% for pancreatic fascial plane, 77% for left renal fascial plane, 55% for peripancreatic fat stranding, 42% for right renal fascial plane, 45% for perivascular fluid, 40% for thickened pancreatic lobular septum and 25% for peripancreatic fluid, which were markedly higher than those on in-phase or SSFSE T2-weighted images (P < 0.001).

CONCLUSION: IEP primarily manifests on non-enhanced MR images as thickened pancreatic fascial plane, left renal fascial plane, peripancreatic fat stranding, and peripancreatic fluid. R-T T2-weighted imaging is more sensitive than in-phase and SSFSE T2-weighted imaging for depicting IEP.

Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy

The aim of this study was to prospectively analyze the possible association of delayed gastric emptying and postoperative pancreatic complications after pancreaticoduodenectomy. Although hospital mortality after pancreaticoduodenectomy is minimal, morbidity is still high; delayed gastric emptying is one of the most frequent complications. Thirty-nine consecutive patients undergoing pancreaticoduodenectomy were included in this study: 14 females and 25 males (median age 65 years; range, 7-82). Delayed gastric emptying was defined as the need for a nasogastric tube or recurrent vomiting that prevented normal feeding on the 10th postoperative day. Blood analysis was performed on postoperative days 4, 6, and 10; Gastrografin examination on day 6; CT scan on days 2 and 5; and drain amylases were measured on day 5. Pancreatitis was defined as pancreatitis changes in CT scan interpreted by an experienced radiologist without knowing other data. Pancreatic fistula was defined according to the recent international recommendations. We had no mortality. Twelve patients (31%) developed delayed gastric emptying. Surgical (9/12 vs. 5/27; P = 0.001) but not medical complications occurred more often in the delayed gastric emptying group. Of the single complications, postoperative CT-detected pancreatitis (6/12 vs. 4/27; P = 0.03) and postoperative pancreatic fistula (5/12 vs. 1/27; P = 0.0007) were significantly associated with delayed gastric emptying compared with the patients without delayed gastric emptying. This pancreatitis was already detected in CT scan on day 2 in most patients (6/10, 60%). In delayed gastric emptying patients, the only parameters in blood analysis that differed significantly from patients without this complication were serum amylase activity (mean +/- SEM, 715 +/- 205 vs. 152 +/- 70 IU/L; P = 0.02), blood leukocyte count (16 +/- 2 vs. 9 +/- 0.6 x 10(9)/L; P = 0.007) and serum C-reactive protein (CRP) concentration (144 +/- 28 vs. 51 +/- 14 mg/L, P = 0.01). Postoperative pancreatic (subclinical) fistula was also associated with postoperative pancreatitis (6/10 vs. 0/29; P = 0.003). Preoperative coronary artery disease (OR = 16; 95% CI, 1.0-241; P = 0.05) and soft pancreatic texture at operation (OR = 9; 95% CI, 1.4-52; P = 0.02) were significant risk factors for the development of postoperative pancreatitis. The diagnosis of delayed gastric emptying after pancreaticoduodenectomy often follows postoperative pancreatitis. Delayed gastric emptying is also associated with postoperative pancreatic fistula, for which this pancreatitis seems to be a risk factor. Preoperative coronary artery disease and soft texture of the pancreas are significant risk factors for postoperative CT-detected pancreatitis.

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II scoring system in predicting acute pancreatitis outcome

AIM: Acute pancreatitis (AP) is a process with variable involvement of regional tissues or organ systems. Multifactorial scales included the Ranson, Acute Physiology and Chronic Health Evaluation (APACHE II) systems and Balthazar computed tomography severity index (CTSI). The purpose of this review study was to assess the accuracy of CTSI, Ranson score, and APACHE II score in course and outcome prediction of AP.

METHODS: We reviewed 121 patients who underwent helical CT within 48 h after onset of symptoms of a first episode of AP between 1999 and 2003. Fourteen inappropriate subjects were excluded; we reviewed the 107 contrast-enhanced CT images to calculate the CTSI. We also reviewed their Ranson and APACHE II score. In addition, complications, duration of hospitalization, mortality rate, and other pathology history also were our comparison parameters.

RESULTS: We classified 85 patients (79%) as having mild AP (CTSI <5) and 22 patients (21%) as having severe AP (CTSI ≥5). In mild group, the mean APACHE II score and Ranson score was 8.61.9 and 2.41.2, and those of severe group was 10.22.1 and 3.10.8, respectively. The most common complication was pseudocyst and abscess and it presented in 21 (20%) patients and their CTSI was 5.91.4. A CTSI ≥5 significantly correlated with death, complication present, and prolonged length of stay. Patients with a CTSI ≥5 were 15 times to die than those CTSI <5, and the prolonged length of stay and complications present were 17 times and 8 times than that in CTSI <5, respectively.

CONCLUSION: CTSI is a useful tool in assessing the severity and outcome of AP and the CTSI ≥5 is an index in our study. Although Ranson score and APACHE II score also are choices to be the predictors for complications, mortality and the length of stay of AP, the sensitivity of them are lower than CTSI.

Early nonenhanced abdominal computed tomography can predict mortality in severe acute pancreatitis

We wondered whether nonenhanced computed tomography (CT) within 48 hours of admission could identify individuals at risk for higher mortality from acute pancreatitis. Data from the international phase III study of the platelet-activating factor-inhibitor Lexipafant was used to analyze noncontrast CT versus acute pancreatitis mortality. Nonenhanced CT examinations of the abdomen from the trial were classified by disease severity (Balthazar grades A-E) and then correlated with patient survival. Among the 477 individuals who underwent CT within 48 hours of admission and 220 individuals who did so over the subsequent 6 days, higher CT grades were associated with increased mortality. Each unit increase in Balthazar grade during the initial 48 hours was associated with an estimated increase in the risk of mortality of 33%, and this trend increased to 50% if pancreatic enlargement and peripancreatic stranding (grades B and C) were combined (P<0.05). CT grade correlated minimally with Ranson, Glasgow, or APACHE II score during the initial 48 hours; however, this correlation improved over 3-8 days. Early nonenhanced abdominal CT in patients with acute pancreatitis is a valuable prognostic indicator of mortality in acute pancreatitis, even among patients without clinical features of severe acute pancreatitis.

Diagnostik und Therapie der akuten Pankreatitis

In acute pancreatitis the evaluation of severity is as important as the diagnosis. If there is evidence for severe pancreatitis, an immediate intensive care of all organ systems is needed, to avoid complications. Besides clinical signs, serum CRP is the most valuable parameter to define severity. According to present knowledge, a CT-scan is only needed in sepsis or multiorgan failure. Non-invasive ventilation should be started early in case of hypoxia. Up to now, no general benefit was detected for antibiotic prophylaxis or enteral nutrition. No consensus exists whether and when endoscopic interventions are superior to surgery in the treatment of infected necrosis.

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome

BACKGROUND AND GOALS

Acute pancreatitis runs an unpredictable course. We prospectively analyzed the prognostic usefulness of four different scoring systems in separately assessing three variables; acute pancreatitis severity, development of organ failure and pancreatic necrosis.

STUDY

78 patients with acute pancreatitis were studied prospectively. Data pertinent to scoring systems were recorded 24 hours (APACHE II and III scores), 48 hours (Ranson score) and 72 hours (Balthazar computed tomography severity index) after admission. Statistical analysis was performed by using receiver operating characteristic curves and by comparing likelihood ratios of positive test (LRPT) for all three outcome variables.

RESULTS

44 patients were classified as mild and 34 as severe pancreatitis. When we compared LRPT, only that for the Balthazar score (11.2157) was able to generate large and conclusive changes from pretest to post-test probability in acute pancreatitis severity prediction. LRPT were 2.4157 for Ranson, 4.0980 for APACHE II and 3.6670 for APACHE III score. The APACHE II and III scores and Ranson criteria performed slightly better than the Balthazar score in predicting organ failure (LRPT: 4.0667, 3.2892, 3.0362 and 1.7941 respectively), while when predicting pancreatic necrosis the APACHE II and III performed slightly better than the Ranson score (LRPT: 2.0769, 2.7500 and 1.7813 respectively).

CONCLUSIONS

In all outcome measures the APACHE scores generate small and of similar extent changes in probability. The Balthazar score is superior to other scoring systems in predicting acute pancreatitis severity and pancreatic necrosis. However the Ranson and APACHE scores perform slightly better with respect to organ failure prediction.