Validation of Lipase and Systemic Inflammatory Response Syndrome as Prognostic Indicators in Pediatric Acute Pancreatitis: A Retrospective Analysis

Acute pancreatitis in childhood - a comparative international study and tale of two cities

BACKGROUNDS

To compare factor(s) contributing to aetiology, management and clinical outcome(s) of paediatric patients acquiring acute pancreatitis (AP) at two major university paediatric surgical centres in Liverpool and Bangkok.

METHODS

All patients (<18 years) with an index diagnosis of AP (ICD 10 coding) during 2006-2016 were studied.

RESULTS

121 patients included n = 79 (65.3%) in Thailand versus n = 42 (34.7%) in the UK centre with no difference(s) in age at diagnosis at 10.4 ± 4.5 and 11.7 ± 6 years. (P = 0.12). Major AP aetiology(s) in Thailand were medications (39.2%) and choledochal cysts (8.9%). In the UK-gallstone disease (21.4%), and medications (16.7%) were leading factors (P < 0.01). Ultrasonography was deployed more frequently in the UK versus Thai centre (74.3% vs. 49.1%; P < 0.01). Pancreatitis was confirmed by imaging in 67.9% (Thai) and 62.9% (UK) patients (P = 0.47). Most patients at both centres had a mild-grade pancreatitis illness (95% Thai vs. 90.5% UK; P = 0.28) while 12.7% of Thai and 19% of UK children developed pancreatitis-related complication (P = 0.37). Overall mortality rate (%) was significantly higher in the Thai versus UK centre (27.8% vs. 9.5%; P = 0.02).

CONCLUSIONS

Aetiology of acute pancreatitis appears to vary between UK and Thailand children. Timely early diagnosis and healthcare pathways may be driven by local patient-related factor(s). The higher mortality (%) observed in Thailand versus UK in this comparative study was linked to underlying co-existent chronic medical condition(s) in vulnerable patient cohorts.

High-density lipoprotein cholesterol level as an independent protective factor against aggravation of acute pancreatitis: a case-control study

Background and aims

At present, evidence on the association between high-density lipoprotein cholesterol (HDL-C) levels and aggravation of acute pancreatitis (AP) is limited. This study aimed to investigate the relationship between the lowest HDL-C level during intensive care units (ICU) stay and AP aggravation and to determine the optimum cutoff lowest HDL-C level.

Methods

Patients admitted to the ICU of the Shandong Provincial Hospital for AP from 2015 to 2021 were included. The lowest HDL-C level during ICU stay was set as the independent variable, and the progression or non-progression to severe AP (SAP) was set as the dependent variable. Univariate and multivariate analyses were performed to determine the relationship between the two variables, and receiver operating characteristic (ROC) curves were plotted to analyze the predictive ability of the lowest HDL-C level for progression to SAP.

Results

This study included 115 patients. The difference in the lowest HDL-C level between the SAP and moderately SAP groups was significant (P < 0.05). After adjusting for covariates, the lowest HDL-C level showed a negative correlation with the occurrence of SAP, with a relative risk of 0.897 (95% confidence interval: 0.827-0.973). The area under the ROC curve for prediction of AP aggravation by the lowest HDL-C level was 0.707, and the optimum cutoff lowest HDL-C level was 0.545 mmol/L.

Conclusion

No less than 0.545 mmol/L of the HDL-C level during ICU stay may be an independent protective factor for the aggravation of AP.

A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, the frequency of which increases in childhood.

AIM

To investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children followed up with the diagnosis of AP. The study also included genetic studies of recurrent cases.

MATERIALS AND METHODS

This retrospective cohort study included pediatric patients <18 years of age with AP who were followed up with recurrent pancreatitis in the Pediatrics Department of a University Hospital between January 2010 and April 2021. Patients who met at least 2 of the 3 criteria defined by the International Pediatric Pancreatitis Study Group (INSPPIRE) were accepted as AP. Demographic, etiological, and clinical data of the patients, developing complications, pathological evaluation of the samples, and genetic analysis results were obtained from the patient files. The obtained data were statistically analyzed using the SPSS version 26.0 program. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). Kolmogorov-Smirnov test, Mann Whitney U test, Chi-square test and Fischer test were used.

RESULTS

Fifty-four (50%) female and 54 (50%) male patients with a mean age of 9.96 ± 4.8 years who met the study criteria were included in the study. In the follow-up, it was reported that acute recurrent pancreatitis developed in 23 (21%) patients and chronic pancreatitis developed in 8 (7%) patients. The most common complaints were abdominal pain (94.4%), and vomiting (60.2%), followed by malnutrition (36.1%), nausea (17.6%), diarrhea (13%), and fever (13%). Etiology could not be determined in 19.4% of the patients. It was noted that the genetic predisposition of the patients played a role in the development of recurrent and chronic pancreatitis. Amylase, lipase, and CRP values, which are among the laboratory parameters showing the severity and prognosis of AP, were found to be significant.

CONCLUSIONS

Sociocultural and demographic data of the patients should also be taken into account. Gene sequences that cause to genetic predisposition should be determined in recurrent and chronic pancreatitis cases. Acute pancreatitis should be considered in the differential diagnosis of patients with frequent abdominal pain and vomiting.

Factors associated with hospital length of stay in children with acute pancreatitis

INTRODUCTION AND AIM

Acute pancreatitis (AP) is the most common cause of pancreatic disease in children. Previous studies have described factors related to days of hospital length of stay (LOS) in children. Our aim was to identify factors associated with LOS in AP.

MATERIALS AND METHODS

A retrospective study was conducted at the Hospital Infantil de México Federico Gómez in Mexico City, encompassing the time frame of January 1, 2017 and March 31, 2019. AP was confirmed by medical chart review, according to the INSPPIRE criteria at the time of hospital admission, in patients below 18 years of age. AP grade was classified, following the NASPGHAN guidelines. Demographic, clinical, biochemical, nutritional, and treatment data were collected. Prolonged hospital LOS was considered that which lasted 7 days or longer.

RESULTS

Fifty-one events (32 patients) were registered. Median LOS was 8 days (IQR 4-14 days). Antibiotic use was significantly associated with longer LOS (OR 31.71; 95% CI: 2.71-370.65; p = 0.006) and early feeding (EF) (within 72 h of admission) was associated with shorter LOS (OR 0.05; 95% CI: 0.001-0.63; p = 0.02). There was no association between LOS and the variables of age, recurrence, grade, etiology, comorbidities, complications, fluid resuscitation, parenteral nutrition, or biochemical characteristics upon admission.

CONCLUSION

Our study, like others, corroborated the fact that EF in the management of AP was associated with fewer days of hospital LOS.

Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis

INTRODUCTION

Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.

METHODS

We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.

RESULTS

We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.

DISCUSSION

Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.

The course of acute pancreatitis in children and potential simple laboratory markers of severity - a single centre retrospective study

AIM

To evaluate the usefulness of routinely measured biochemical and complete blood count parameters as potential markers of the severity of pediatric acute pancreatitis.

METHODS

The retrospective study included children with acute pancreatitis hospitalised over a 3-year period. Demographic, clinical and laboratory data were collected.

RESULTS

55 patients were enrolled in the study. Mild acute pancreatitis was diagnosed in 45 children (82%), moderately severe in 7 (13%), and severe in 3 patients (5%). Together 10 children (18%) were categorized into a single severe group. Children with severe acute pancreatitis had higher white blood cell and platelet counts on admission as well as a C-reactive protein concentration after 48 hours. The C-reactive protein concentration after 48 hours (cut-off: 127,2 mg/l) and the white blood cell count on admission (cut-off: 13,5x10³ /μl) were found to be statistically significant markers in predicting the severity of the disease. The C-reactive protein concentration after 48 hours was demonstrated as an independent predictor.

CONCLUSION

Severe acute pancreatitis is observed in a quite significant percentage of children. The white blood cell count on admission and the C-reactive protein concentration after 48 hours (as an independent predictor) may be potential simple laboratory markers of the severity of the disease.

Development and validation of a nomogram for early assessment the severity of acute pancreatitis

BACKGROUND

Acute pancreatitis is an acute inflammatory disorder of the pancreas, and severe acute pancreatitis is associated with high mortality. Early assessment the severity of AP has an important significance for improving clinical outcomes. Our object aimed to develop a nomogram with high simplicity and rapidity for predicting the severity of acute pancreatitis.

METHODS

Patients admitted to the Hunan Provincial People's Hospital within 72 h from onset of AP from January 2010 and December 2020 were enrolled to establish a nomogram. Independent predictors were determined using univariate and multivariate analysis and then assembled to construct a predicting nomogram. The performance of proposed nomogram was evaluated by Brier score and Harrell's concordance index (C-index). Meanwhile, clinical data of AP patients from January 2021 to January 2022 were collected for external validation.

RESULTS

Album (OR 0.891, 95%CI 0.867-0.917), calcium (OR 0.151, 95%CI 0.084-0.273), neutrophil to lymphocyte ratio (OR 1.055, 95%CI 1.023-1.088) and systemic inflammatory response syndrome (OR 6.292, 95%CI 4.459-8.879) were identified as independent factors of SAP after univariate and multivariate analysis (p < .05). A predictive nomogram was accordingly established using these four independent variables. The internally verified C-index was 0.796 (95% CI 0.773-0.818), Brier score was 0.138. The externally verified C index was 0.820 (95% CI 0.754-0.887).

CONCLUSION

A nomogram for predicting the severity of AP was well developed, it may be of great significance for clinicians to quickly assess the progress of AP and choose more-targeted strategies.

Etiology and classification of acute pancreatitis in children admitted to ICU using the Pediatric Sequential Organ Failure Assessment (pSOFA) score

BACKGROUND

Pediatric acute pancreatitis (AP) is rare but increasing. Severe AP is associated with higher morbidity and mortality. However, there are no universally accepted prognostic criteria for AP.

METHODS

This retrospective study included children with AP admitted to an intensive care unit (ICU) of our tertiary pediatric center between January 2009 and December 2018. The severity of organ dysfunction in AP was assessed according to the modified Atlanta criteria using the Pediatric Sequential Organ Failure Assessment (pSOFA) and Computed Tomography Severity Index (CTSI).

RESULTS

Seventy acute episodes of AP were evaluated in 55 children with primary pancreatitis. In addition, secondary AP was diagnosed in 15 patients originally admitted to ICU for different indications. Mild AP [no organ dysfunction, normal computed tomography (CT) finding] was the most prevalent (64/85 episodes in 49 children), followed by moderate AP (15 children; pSOFA 2-9 points, CTSI 3-4 points on admission). Severe AP (pSOFA 4-17 points, CTSI 6-10 points) was diagnosed in 6 children with traumatic or secondary AP. The most frequent etiologies of primary AP episodes were idiopathic (39%) and biliary (31%). Children with idiopathic AP had frequent relapses and comorbidities. Hereditary AP was typically mild, but presented with high pancreatic enzyme levels and recurrence rates. Admission at ICU and an interval without enteral nutrition (EN) were relatively short in drug-induced AP and relatively long in secondary and traumatic AP. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 13 patients with biliary AP and in 4 patients with traumatic AP. No AP-related death was observed.

CONCLUSION

pSOFA score accurately reflects the severity and prognosis of AP in children.

Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies

For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.

Order Set Use and Education Association With Pediatric Acute Pancreatitis Outcomes

BACKGROUND

The management of acute pancreatitis (AP) in children was historically derived from adult practice recommendations. Pediatric-specific recommendations for treatment of AP were recently developed by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, but their impact on clinical outcomes has yet to be evaluated. We developed an AP order set on the basis of these recommendations to assess impact on clinical outcomes.

METHODS

Patients admitted to a single center with 3 children's hospitals in 2017 and 2018 for isolated AP were included in a retrospective review. Patient demographic data, order set use, treatment variables (eg, fluid type, rate, type and timing of diet initiation, and narcotic use), and outcome variables (eg, length of stay [LOS], PICU admission, and 30-day readmission) were collected. Mixed-effects modeling was used to estimate the impact of order set use on clinical outcomes.

RESULTS

There were 159 pancreatitis encounters and 137 unique patients who met inclusion criteria. In 2018, when using the log transform of LOS in a linear mixed-effects model for clustering by hospital, there was a 10% decrease in mean LOS, but this failed to reach statistical significance (P = .30). Among the 107 encounters who received at least 1 dose of narcotic, there were significantly fewer doses prescribed after implementation of the order set: mean (SD) of5.22 (2.86) vs 3.59 (2.47) (P < .001). Thirty-day readmission (P = .25) and PICU admission rates (P = .31) were not different between years.

CONCLUSIONS

The implementation of a pancreatitis order set is associated with a significant decrease in narcotic use in pediatric patients with AP without increasing readmission rates or PICU admissions.

Risk factors of recurrent acute pancreatitis after conservative treatment in pediatric population: a single-center study

Background

Although complete resolution and recovery occurs in most children with an initial attack of acute pancreatitis (AP), a subset of children may progress to recurrent AP (RAP). RAP has serious effects to the individual and the socioeconomic burden. The aim of this project was to identify the independent risk factors for pediatric RAP so as to provide evidence for its prevention, early diagnosis and treatment.

Methods

A retrospective cohort study of children discharged from Tianjin Children’s Hospital from June 2017 to January 2020 was performed. Demographic and clinical variables, treatment strategies, clinical course and outcomes were collected. Independent risk factors of RAP were identified using the logistic regression model.

Results

Of the total 96 enrolled children, 30 (31.3%) developed RAP during the follow-up period. The majority (27/30, 90%) of the children with AP developed RAP within 6 months of their first AP attack. The presence of systemic inflammatory response syndrome (SIRS) [odds ratio (OR)=6.652, 95% confidence interval (CI) 1.989 to 22.247], fasting time (OR=1.267, 95% CI 1.104 to 1.583), whether meet all three AP diagnostic criteria (OR=7.438, 95% CI 1.346 to 41.103) and abnormal amylase/lipase value on the seventh day of hospitalization (OR=3.601, 95% CI 0.972 to 13.342) were independent risk factors of RAP in children.

Conclusions

Most children who developed RAP had progressed within 6 months after their first episode of AP. RAP was more common in children who met all three AP diagnostic criteria at initial attack and in children with SIRS, long fasting time and abnormal amylase/lipase value on the seventh day of hospitalization.