Validation of the harmless acute pancreatitis score in predicting nonsevere course of acute pancreatitis

The causality between use of glucocorticoids and risk of pancreatitis: a Mendelian randomization study

BACKGROUND AND AIM

To date, the association between glucocorticoid use and the risk of pancreatitis remains controversial. The aim of this study was the investigation of this possible relationship.

METHODS

We carried out a two-sample Mendelian randomization (MR) analysis using GWAS data from European ancestry, East Asian descendants and the FinnGen Biobank Consortium to evaluate this potential causal relationship. Genetic variants associated with glucocorticoid use were selected based on genome-wide significance (p < 5×10-8).

RESULTS

Our MR analysis of European ancestry data revealed no significant causal relationship between glucocorticoid use and AP (IVW: OR=1.084, 95% CI= 0.945-1.242, P=0.249; MR-Egger: OR=1.049, 95% CI= 0.686-1.603, P=0.828; weighted median: OR=1.026, 95% CI= 0.863-1.219, P=0.775) or CP (IVW: OR=1.027, 95% CI= 0.850-1.240, P=0.785; MR-Egger: OR= 1.625, 95% CI= 0.913-2.890, P= 0.111; weighted median: OR= 1.176, 95% CI= 0.909-1.523, P= 0.218). Sensitivity analyses, including MR-Egger and MR-PRESSO, indicated no evidence of pleiotropy or heterogeneity, confirming the robustness of our findings. Multivariable MR analysis adjusted for alcohol consumption, BMI, cholelithiasis and C-reactive protein levels supported these findings. Replicated analysis was performed on datasets from the FinnGen Biobank Consortium and East Asian descendants, and similar results were obtained.

CONCLUSIONS

This MR analysis suggests that there is no causal association between glucocorticoid use and the risk of pancreatitis.

Predicting in-hospital mortality in patients with acute pancreatitis in the ED: a direct, retrospective comparison of four clinical and radiological prognostic scores

BACKGROUND

Acute pancreatitis can be a severe disease that significantly impacts patients' quality of life and outcome. The clinical course is variable and predictive scoring systems have a debated role in early prognosis. This study aims to compare the prognostic accuracy of Balthazar, BISAP, HAPS and SOFA scores in the prediction of in-hospital mortality in patients with acute pancreatitis.

METHODS

This is a retrospective, single-center cohort study conducted in the Emergency Department of a third-level university hospital. Patients aged >18 years admitted from 1st January 2018 to 31st December 2021 for the first episode of acute pancreatitis were included.

RESULTS

A total of 385 patients (mean age of 65.4 years and 1.8% in-hospital mortality) were studied. Balthazar, BISAP and SOFA scores were significantly higher in patients with in-hospital mortality and AUROCs were equal to 0.95 (95% CI 0.91-0.99, P<0.001), 0.96 (95% CI 0.89-1, P=0.001), 0.91 (95% CI 0.81-1, P=0.001) with no differences among them and absence of in-hospital mortality in patients with HAPS=0.

CONCLUSIONS

Our data support the concept that clinical prediction scores can be useful for risk stratification in the Emergency Department. However, no single score has shown superiority in predicting acute pancreatitis-related in-hospital mortality among tested tools.

Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence

Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease of the pancreas, with clinical management determined by the severity of the disease. Diagnosis, severity prediction, and prognosis assessment of AP typically involve the use of imaging technologies, such as computed tomography, magnetic resonance imaging, and ultrasound, and scoring systems, including Ranson, Acute Physiology and Chronic Health Evaluation II, and Bedside Index for Severity in AP scores. Computed tomography is considered the gold standard imaging modality for AP due to its high sensitivity and specificity, while magnetic resonance imaging and ultrasound can provide additional information on biliary obstruction and vascular complications. Scoring systems utilize clinical and laboratory parameters to classify AP patients into mild, moderate, or severe categories, guiding treatment decisions, such as intensive care unit admission, early enteral feeding, and antibiotic use. Despite the central role of imaging technologies and scoring systems in AP management, these methods have limitations in terms of accuracy, reproducibility, practicality and economics. Recent advancements of artificial intelligence (AI) provide new opportunities to enhance their performance by analyzing vast amounts of clinical and imaging data. AI algorithms can analyze large amounts of clinical and imaging data, identify scoring system patterns, and predict the clinical course of disease. AI-based models have shown promising results in predicting the severity and mortality of AP, but further validation and standardization are required before widespread clinical application. In addition, understanding the correlation between these three technologies will aid in developing new methods that can accurately, sensitively, and specifically be used in the diagnosis, severity prediction, and prognosis assessment of AP through complementary advantages.

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.

Comparative Evaluation of Harmless Acute Pancreatitis Score (HAPS) and Bedside Index of Severity in Acute Pancreatitis (BISAP) Scoring System in the Stratification of Prognosis in Acute Pancreatitis

Acute pancreatitis is a common disease in patients presenting to the emergency room in any hospital. The most common causes are alcohol ingestion and gallstone disease. Diagnosis is usually based on clinical findings and elevated serum amylase and lipase levels. Imaging is often not necessary but may be used to confirm the diagnosis or rule out any other pathology or to evaluate for any complications. The majority of patients will have a mild, self-limiting disease but others may develop a severe fulminant course with organ failure. These patients are at high risk of developing complications, morbidity or mortality. Treatment of acute pancreatitis includes supportive treatment with antibiotics, fluids, analgesics and early enteral feeding. Several scores have been developed to predict the course of pancreatitis and help make informed decisions, monitoring and timely intervention. The majority of them are complicated, require extensive and expensive interventions or require time. Harmless acute pancreatitis score (HAPS) is one such score that is easy to calculate and is done at the time of admission, bedside index of severity in acute pancreatitis (BISAP) is another one requiring more parameters. The parameters used to calculate it are easily available and can be done at a majority of healthcare facilities in developing countries. HAPS thus seems to be a good option in aiding doctors in assessing acute pancreatitis. It may be considered as a standard scoring for acute pancreatitis for early and effective management. We have tried to study and compare the superiority of HAPS over BISAP in predicting prognosis in acute pancreatitis.

Harmless Acute Pancreatitis Negative among Cases of Acute Pancreatitis in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Acute Pancreatitis is a common disease, diagnosed in about 3% of cases presenting with abdominal pain. Severe disease with multiple systemic complications develops in 10-20% of the cases which require intensive care in specialized centres. Harmless acute pancreatitis score is a simple and economical score predicting the non-severe course of disease within 30 minutes of admission. The aim of our study was to find the prevalence of harmless (harmless acute pancreatitis) among cases of acute pancreatitis in a tertiary care centre.

METHODS

A descriptive cross-sectional study was conducted after obtaining the ethical approval (Reference no. 344/2076/77). The study was carried out from September 2019 to February 2020 taking 50 patients with the first attack of acute pancreatitis. Convenient sampling was done. Harmless acute pancreatitis score prediction of severe disease and final outcome as severe or non-severe was noted with predefined severity criteria. Data were entered in Microsoft Excel and Statistical Package for the Social Sciences and results represented in tables and charts. Point estimate at 95% was done and frequency and percentage were calculated.

RESULTS

Out of 50 patients with first attack of acute pancreatitis, using the harmless acute pancreatitis score, the prevalence of harmless acute pancreatitis was 22 (56%) (44.45-67.5 at 90% Confidence Interval).

CONCLUSIONS

The harmless acute pancreatitis score is an easy, less expensive, quick and promising early scoring system for prediction of non-severe courses of acute pancreatitis. The prevalence of harmless (harmless acute pancreatitis) among cases of acute pancreatitis was found to be similar to other studies.

The harmless acute pancreatitis score (HAPS) identifies non-severe patients: A systematic review and meta-analysis

INTRODUCTION

We previously described a scoring system to identify patients with harmless acute pancreatitis as defined by absence of pancreatic necrosis, no need for artificial ventilation or dialysis, and non-fatal course. This scoring system, the Harmless Acute Pancreatitis Score (HAPS), can be quickly calculated from three parameters: absence of abdominal tenderness or rebound, normal hematocrit and normal creatinine level. We aim to assess the positive predictive value (PPV) of the HAPS by performing a meta-analysis of subsequently published studies.

METHODS

We performed a literature search using Pubmed, Web of Science^TM and Google Scholar. We used random effects models, with maximum likelihood estimates, to estimate the PPV of HAPS. We produced forest plots and used the I² statistic to quantify heterogeneity.

RESULTS

Twenty reports covering 6374 patients were identified. The overall PPV based on 16 studies that closely followed the original description of the HAPS system was 97% (95%CI 95-99%) with significant heterogeneity (I² = 76%; P < 0.01). For 11 studies in which HAPS was used to identify patients with mild AP, the overall PPV dropped to 83% (74-91%). For 8 studies in which HAPS was used to predict non-fatal course the overall PPV was 98% (97-100%).

CONCLUSION

The HAPS, if used as originally defined, accurately identifies patients with non-severe AP who will not require ICU care and facilitate selection of patients who can be discharged after a short stay on a general ward or can even be cared for at home. This could free hospital beds for other purposes and decrease healthcare costs.

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.

[Harmless acute pancreatitis score on admission can accurately predict mild acute pancreatitis]

OBJECTIVE

To evaluate the efficacy of harmless acute pancreatitis score (HAPS) on admission for predicting mild acute pancreatitis (MAP).

METHODS

We prospectively collected the data from consecutive AP patients admitted to West China Hospital between January, 2016 and August, 2017, and HAPS scores were calculated on admission. The clinical outcomes of the patients with harmless AP (HAPS>2) and those with non-harmless AP (HAPS≤2) were compared. MAP was defined based on the severity classification of 2012 Revised Atlanta guidelines. The area under the curve (AUC) of the receiver- operator characteristic curve (ROC), specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of HAPS on admission for predicting MAP were analyzed.

RESULTS

Of the 703 patients with AP analyzed, 182 were predicted to have harmless AP and 521 to have non- harmless AP, and the patients in the latter group had significantly worse clinical outcomes (P < 0.001). The total number of patients with MAP was 359 in the study. The specificity, the sensitivity, the PPV and NPV of HAPS on admission for predicting MAP was 97.7% (95% CI: 95.4-99.0), 48.2% (95% CI: 42.9-53.3), 95.6% (95% CI: 91.5- 98.1) and 64.1% (95% CI: 59.8- 68.2), respectively, and the AUC was 0.749 (95% CI: 0.72- 0.78).

CONCLUSIONS

HAPS score on admission can accurately predict MAP.

Association of total cholesterol with severe acute pancreatitis: A U-shaped relationship

BACKGROUND & AIMS

There is no consensus on relationship between total cholesterol levels and incidence of severe acute pancreatitis (SAP). The aim of this study was to investigate the relation between total cholesterol (TC) and the disease severity of acute pancreatitis.

METHODS

We conducted a cross-sectional study on patients with acute pancreatitis between April 2012 and December 2015 in a university hospital. Fasting blood total cholesterol (TC) was assayed within 24 h of admission, as well as 3-5 days, 7-9 days and 13-15 days during hospitalization. Time interval before admission, age, gender, Body Mass Index, hypertension, diabetes mellitus, alcohol consumption, smoking, etiology and albumin were recorded as potential confounding factors. To assess the pattern of relationship of TC and SAP, we used restricted cubic spline analysis with multivariable logistic regression analysis. We also compared total cholesterol concentrations between patients with or without SAP at different time points.

RESULTS

648 patients (median age: 47.5 years; 62.4% man) were enrolled. The incidence of SAP was 10%. A U-shaped association of TC level within 24 h of admission with severity was observed in acute pancreatitis. Patients with low TC levels (<160 mg/dL) and high TC levels (>240 mg/dL) had a significantly higher incidence of SAP and protracted hospital stays when compared to moderate TC levels (160-240 mg/dL). Low total cholesterol levels (OR 2.72; 95 %eCI 1.27-5.83; P = 0.01) and high total cholesterol levels (OR 2.54; 95 %eCI 1.09-5.89; P = 0.03), were still independently associated with development of SAP after adjusting for potential confounding factors. Longitudinal cohort study indicated that patients with SAP had lower total cholesterol concentrations among 3-15 days after admission compared to patients without SAP (P < 0.001).

CONCLUSIONS

Both low TC level (<160 mg/dL) and high TC (>240 mg/dL) within 24 h of admission is independently associated with an increased risk of SAP.

The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity?

BACKGROUND

Using revised Atlanta classification defined outcomes, we compare absolute values in C-reactive protein (CRP), with interval changes in CRP, for severity stratification in acute pancreatitis (AP).

METHODS

A retrospective study of all first incidence AP was conducted over a 5-year period. Interval change in CRP values from admission to day 1, 2 and 3 was compared against the absolute values. Receiver-operator characteristic (ROC) curve and likelihood ratios (LRs) were used to compare ability to predict severe and mild disease.

RESULTS

337 cases of first incidence AP were included in our analysis. ROC curve analysis demonstrated the second day as the most useful time for repeat CRP measurement. A CRP interval change >90 mg/dL at 48 h (+LR 2.15, -LR 0.26) was equivalent to an absolute value of >150 mg/dL within 48 h (+LR 2.32, -LR 0.25). The optimal cut-off for absolute CRP based on new, more stringent definition of severity was >190 mg/dL (+LR 2.72, -LR 0.24).

CONCLUSION

Interval change in CRP is a comparable measure to absolute CRP in the prognostication of AP severity. This study suggests a rise of >90 mg/dL from admission or an absolute value of >190 mg/dL at 48 h predicts severe disease with the greatest accuracy.

IL-6 and CRP are superior in early differentiation between mild and non-mild acute pancreatitis

BACKGROUND

The revised Atlanta classification on acute pancreatitis (AP) presents distinct criteria for severity categorization. Due to the lack of reliable prognostic markers, a majority of patients with AP are currently hospitalized and initially managed identically. As incidence and financial costs are rising the need for early severity differentiation will increase. This study aimed to investigate the capacity of biomarkers to stratify AP patients during the initial course of the disease.

METHODS

Patients with AP were prospectively enrolled and dichotomized into mild or non-mild (moderately severe and severe AP) according to the revised Atlanta classification. Serum samples taken within 13-36 h after onset of disease were analyzed for 20 biomarkers. Through receiver operating curves cut-off levels were set for 5 biomarkers whose stratifying ability was further analyzed. Additionally, the patients were classified according to the harmless acute pancreatitis score (HAPS).

RESULTS

Among the 175 patients, 70.9% had mild and 29.1% non-mild AP. CRP and IL-6 combined, with cut-off levels 57.0 and 23.6 respectively, demonstrated superior discriminative capacity with an area under the curve of 0.803, sensitivity 98%, specificity 54% and a positive and negative likelihood ratio of 2.1 and 0.06 for the non-mild group. Regarding the mild group likelihood ratios were positive 26.5 and negative 0.48. The identification potential of the HAPS was generally inferior when compared to CRP plus IL-6.

CONCLUSIONS

In this study CRP and IL-6 demonstrate a clinically relevant capacity to differentiate mild from non-mild AP early in the course of AP.

Acute pancreatitis

PURPOSE OF REVIEW

To summarize recent data on classification systems, cause, risk factors, severity prediction, nutrition, and drug treatment of acute pancreatitis.

RECENT FINDINGS

Comparison of the Revised Atlanta Classification and Determinant Based Classification has shown heterogeneous results. Simvastatin has a protective effect against acute pancreatitis. Young black male, alcohol, smoldering symptoms, and subsequent diagnosis of chronic pancreatitis are risk factors associated with readmissions after acute pancreatitis. A reliable clinical or laboratory marker or a scoring system to predict severity is lacking. The PYTHON trial has shown that oral feeding with on demand nasoenteric tube feeding after 72 h is as good as nasoenteric tube feeding within 24 h in preventing infections in predicted severe acute pancreatitis. Male sex, multiple organ failure, extent of pancreatic necrosis, and heterogeneous collection are factors associated with failure of percutaneous drainage of pancreatic collections.

SUMMARY

The newly proposed classification systems of acute pancreatitis need to be evaluated more critically. New biomarkers are needed for severity prediction. Further well designed studies are required to assess the type of enteral nutritional formulations for acute pancreatitis. The optimal minimally invasive method or combination to debride the necrotic collections is evolving. There is a great need for a drug to treat the disease early on to prevent morbidity and mortality.

Acute pancreatitis

Acute pancreatitis, an inflammatory disorder of the pancreas, is the leading cause of admission to hospital for gastrointestinal disorders in the USA and many other countries. Gallstones and alcohol misuse are long-established risk factors, but several new causes have emerged that, together with new aspects of pathophysiology, improve understanding of the disorder. As incidence (and admission rates) of acute pancreatitis increase, so does the demand for effective management. We review how to manage patients with acute pancreatitis, paying attention to diagnosis, differential diagnosis, complications, prognostic factors, treatment, and prevention of second attacks, and the possible transition from acute to chronic pancreatitis.

Comparative analysis of selected scales to assess prognosis in acute pancreatitis

OBJECTIVE

To evaluate the utility of selected scales to prognosticate the severity and risk for death among patients with acute pancreatitis (AP) according to the revised Atlanta classification published in 2012.

METHODS

Prospective data regarding patients hospitalized due to AP were analyzed. The final analysis included a total of 1014 patients. The bedside index for severity in acute pancreatitis (BISAP), Panc 3 scores and Ranson scales were calculated using data from the first 24 h of admission.

RESULTS

Mild AP was diagnosed in 822 (81.1%) cases, moderate in 122 (12%) and severe in 70 (6.9%); 38 (3.7%) patients died. The main causes of AP were cholelithiasis (34%) and alcohol abuse (26.7%). Recurrence of AP was observed in 244 (24.1%) patients. In prognosticating the severity of AP, the most useful scale proved to be the Acute Physiology and Chronic Health Evaluation (APACHE) II (area under the curve [AUC] 0.724 [95% CI 0.655 to 0.793]), followed by BISAP (AUC 0.693 [95% CI 0.622 to 0.763]). In prognosticating a moderate versus mild course of AP, the CT severity index proved to be the most decisive (AUC 0.819 [95% CI 0.767 to 0.871]). Regarding prognosis for death, APACHE II had the highest predictive value (AUC 0.726 [95% CI 0.621 to 0.83]); however, a similar sensitivity was observed using the BISAP scale (AUC 0.707 [95% CI 0.618 to 0.797]).

CONCLUSIONS

Scoring systems used in prognosticating the course of the disease vary with regard to sensitivity and specificity. The CT severity index scoring system showed the highest precision in prognosticating moderately severe AP (as per the revised Atlanta criteria, 2012); however, in prognosticating a severe course of disease and mortality, APACHE II proved to have the greatest predictive value.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

Management of acute pancreatitis

Acute pancreatitis (AP) is a common medical condition with extensive morbidity and mortality. Approximately 210,000 Americans are hospitalized each year; and 5% of patients with AP will die. It is also an expensive condition, costing 2.6 billion dollars (United States) in 2009 alone. Moreover, the incidence is increasing - the National Hospital Discharge Survey showed hospitalizations increased from 78 per 100,000 in 2007 to 90 per 100,000 just three years later in 2010. There is no proven pharmacologic entity to treat the inflammatory response associated with acute pancreatitis; supportive care with IV fluids, bowel rest and pain control are the mainstays of therapy. Recently, new developments to help increase survival and minimize morbidity with several key interventions have been investigated. This summary highlights new studies and meta-analyses to provide current opinion on treatment of this morbid condition.

Utility of the "harmless acute pancreatitis score" in predicting a non-severe course of acute pancreatitis: a pilot study in an Indian cohort

BACKGROUND

Several severity predictors have been tested for assessing acute pancreatitis (AP). The recently described harmless acute pancreatitis score (HAPS) could be an ideal predictor for Indian patients at the community level. We validate this system in the current study.

METHODS

This was a prospective pilot study conducted at a tertiary center from July 2010 to December 2011. Consecutive directly admitted patients over 18 years with a documented first episode of AP were enrolled and followed for at least 12 months after discharge/till death. HAPS was defined as absence of rebound abdominal tenderness, serum creatinine of <2 mg/dL, and hematocrit of <43 for male and <39.6 for female patients at the time of admission; and it was considered positive if the patient fulfilled all three criteria. Study outcomes included total hospital stay, need for intensive care unit (ICU), ICU stay, development of local complications, organ failure, hospital-acquired infections (including infected necrosis), and in-hospital mortality.

RESULTS

There were a total of 103 patients directly admitted with AP during the study period, out of which, 23 were excluded. Forty-seven (58.8 %) patients were positive for HAPS. Of these, 44 (93.6 %) had an eventual non-severe (mild) clinical course with odds ratio 17.6 (95 % CI 4.5-68.3). Sensitivity, specificity, positive and negative predictive value, and receiver operating characteristics area under the curve of HAPS as a predictor of non-severe disease were 76.3 (66.9-86.4), 85.7 (78.0-96.8), 93.8 (88.5-98.6), 56.6 (45.4-73.6), and 84.8 (76.9-92.7) respectively.

CONCLUSION

This study validated the utility of HAPS for directly admitted patients with AP in India. Large-scale multicenter community-based studies need to be performed.

Update to the management of pediatric acute pancreatitis: highlighting areas in need of research

Acute pancreatitis is an emerging problem in pediatrics, with an incidence that is rising in the last 2 decades. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis. Prospective multicenter studies defining optimal management of pediatric pancreatitis are needed to guide care and improve outcomes for this patient population.

Acute pancreatitis--costs for healthcare and loss of production

OBJECTIVE. Severity of acute pancreatitis (AP) can vary from a mild to a fulminant disease with high morbidity and mortality. Cost analysis has, however, hitherto been sparse. The aim of this study was to calculate the cost of acute pancreatitis, both including hospital costs and costs due to loss of production. MATERIAL AND METHODS. All adult patients treated at Skane University Hospital, Lund, during 2009-2010, were included. A severity grading was conducted and cost analysis was performed on an individual basis. RESULTS. Two hundred and fifty-two patients with altogether 307 admissions were identified. Mean age was 60 ± 19 years, and 121 patients (48%) were men. Severe AP (SAP) was diagnosed in 38 patients (12%). Thirteen patients (5%) died. Acute biliary pancreatitis was more costly than alcohol induced AP (p < 0.001). Total costs for treating mild AP (MAP) in patients ≤65 years old was lower (p = 0.001) and costs for SAP was higher (p = 0.024), as compared to older patients. The overall hospital cost and cost for loss of production was per person in mean €5,100 ± 2,400 for MAP and €28,200 ± 38,100 for SAP (p < 0.001). The costs for treating AP during the two-year-long study period were in mean €9,762 ± 19,778 per patient. Extrapolated to a national perspective, the annual financial burden for AP in Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants. CONCLUSIONS. The costs of treating AP are high, especially in severe cases with a long ICU stay. These results highlight the need to optimize care and continue the identification and focus on SAP, in order to try to limit organ failure and infectious complications.

Criteria for the diagnosis and severity stratification of acute pancreatitis

Recent diagnostic and therapeutic progress for severe acute pancreatitis (SAP) remarkably decreased the case-mortality rate. To further decrease the mortality rate of SAP, it is important to precisely evaluate the severity at an early stage, and initiate appropriate treatment as early as possible. Research Committee of Intractable Diseases of the Pancreas in Japan developed simpler criteria combining routinely available data with clinical signs. Severity can be evaluated by laboratory examinations or by clinical signs, reducing the defect values of the severity factors. Moreover, the severity criteria considered laboratory/clinical severity scores and contrast-enhanced computed tomography (CE-CT) findings as independent risk factors. Thus, CE-CT scans are not necessarily required to evaluate the severity of acute pancreatitis. There was no fatal case in mild AP diagnosed by the CE-CT severity score, whereas case-mortality rate in those with SAP was 14.8%. Case-mortality of SAP that fulfilled both the laboratory/clinical and the CE-CT severity criteria was 30.8%. It is recommended, therefore, to perform CE-CT examination to clarify the prognosis in those patients who were diagnosed as SAP by laboratory/clinical severity criteria. Because the mortality rate of these patients with SAP is high, such patients should be transferred to advanced medical units.

Predictors of adverse outcomes in acute pancreatitis: new horizons

Acute pancreatitis (AP) continues to be a clinical challenge. The mortality of patients with AP with adverse outcomes like organ failure and infected necrosis can be as high as 43 %. Highly accurate predictors of adverse outcomes are necessary to identify the high-risk patients so that they can be meticulously monitored and managed. However, there are no ideal predictors till date. Over the past several years, a number of single- and multi-parameter predictors have been identified and tested for prediction of adverse outcomes in AP. Out of the different tools tested, blood urea nitrogen and the harmless acute pancreatitis score appears to be useful and feasible in the management of AP under Indian conditions. Other single-parameter predictors like serum creatinine, hematocrit, erythrocyte sedimentation rate, C-reactive protein, and D-dimer need to be put to further tests in high-quality prospective studies with large sample size at the community level. Multi-parameter prediction tools like the bedside index of severity of acute pancreatitis may not be appealing in day-to-day clinical practice.

The "golden hours" of management in acute pancreatitis

In the past decade, a significant amount of active and enthusiastic research has changed the way we treat acute pancreatitis (AP) within the first 24 hours of presentation. We highlight the importance of rapid initiation of treatment to help prevent the considerable morbidity and mortality that can occur when interventions are delayed. We review recent data that validate simple and accurate tools for prognostication of AP to replace the older, more tedious methods that relied on numerous factors and required up to 48 hours to complete. Additionally, we aim to provide evidence-based guidelines and end points for fluid resuscitation. Finally, we hope to bring clarification to two previously controversial topics in AP treatment: the use of prophylactic antibiotics and early endoscopic retrograde cholangiopancreatography.