Problems in the diagnosis and management of acute pancreatitis

Haemorrhagic complication of acute necrotizing pancreatitis presenting with sudden death

Certain complications of acute pancreatitis may lead to death, and of these, haemorrhage caused by rupture of a peri-pancreatic vessel is among the most dangerous. The case reported here was remarkable because the onset of acute necrotizing pancreatitis was completely asymptomatic and the severe haemorrhage of the portal vein that caused the patient's death was only discovered at autopsy. The onset of abdominal pain was immediately followed by death.

Acute pancreatitis: results of a protocol of management

To assess prognostication and therapy of 100 patients with acute pancreatitis, a randomized prospective multicentre clinical trial was commenced in August 1982. This study examines the usefulness of four parameters (sex, age, serum amylase and serum aspartate aminotransferase), coincidentally used as part of accurate and reliable prediction of severity of disease, in predicting gallstone aetiology, with an accuracy of 82%. The cost effectiveness and morbidity associated with the treatment of pancreatitis is also examined; patients with mild to moderately severe pancreatitis are better managed with a peripheral intravenous crystalloid solution and routine ward observations, rather than with supplementary urinary catheter and antibiotics. Conclusions about the optimum treatment of patients with severe pancreatitis cannot be made; certainly peritoneal lavage as adjunctive therapy, which has not been shown to be beneficial in larger series of patients with severe pancreatitis, more than doubles the cost per patient and is thus probably not cost effective. The overall morality in this series is 2%.

Predictors of severity of attacks of acute pancreatitis

In an attempt to reduce the current morbidity and mortality from acute pancreatitis, a prospective randomized multicentre trial was begun in August 1982. Part of this study involved an attempt to develop a set of prognostic indices which would identify patients with severe pancreatitis on the day of admission to hospital. An analysis of a predetermined set of 10 indices (age, blood pressure, white cell count, blood urea, serum calcium, aspartate aminotransferase, lactate dehydrogenase, blood glucose, arterial blood pH and PO2) on admission to hospital, in 100 patients, is presented. The positive predictive value of these indices (excluding age) is 90%. These indices are readily available in most hospitals, and allow the early identification of the high risk patient with an accuracy equal to or better than that previously reported.

Acute pancreatitis

This paper provides a review of recent advances in the understanding and management of acute pancreatitis. The mortality of acute severe pancreatitis remains disappointingly high. While there have been relatively few recent advances in the surgical management of acute pancreatitis, several nonsurgical developments appear promising.