Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan

Association Between Serum Triglyceride Levels and the Severity of Acute Pancreatitis: A Retrospective Study

Background Acute pancreatitis (AP) is a potentially fatal condition with a poor prognosis if it escalates to its severe form. The pathophysiology of AP has been associated with serum triglyceride (TG) levels. However, the relationship between serum triglyceride (TG) levels and AP severity remains poorly understood. Therefore, this study aimed to investigate the correlation between serum TG levels and the severity of AP. Methods This retrospective study was conducted at Benazir Bhutto Hospital (BBH) in Rawalpindi, Pakistan, from January 2023 to January 2024, among 210 patients with AP. Data was gathered on a self-devised proforma from medical records. The Ranson criteria score was utilized to assess the severity of AP. Patients were divided into two groups: patients with non-severe AP and patients with severe AP on the basis of their Ranson criteria score. Data analysis was done in the Statistical Package for Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY) through the chi-squared test, independent t-test, Pearson's correlation, and a simple linear regression analysis. The p-value of less than 0.05 was set as significant. Results Of the 210 patients, 135 (64.28%) had non-severe AP, while 75 (35.72%) had severe AP. Values of the variables including gender, age, white blood cell (WBC) count, serum aspartate transaminase (AST) levels, serum blood glucose levels, serum lactate dehydrogenase (LDH) levels, Ranson score, serum amylase levels, serum lipase levels, body mass index, serum TG levels, and length of hospital stay were significantly (p < 0.05) higher among the patients with severe AP. Pearson's correlation indicated that serum TG levels were positively and significantly associated with the Ranson scores (coefficient {r} = 0.80; p < 0.003). Moreover, linear regression analysis confirmed serum TG level as a significant predictor of AP severity, with a beta coefficient (β) of 3.21 and a 95% confidence interval (CI) of 1.82-4.72 (p < 0.002). The frequency of clinical outcomes such as pancreatic necrosis, intensive care unit (ICU) admission, and mortality was significantly higher among the patients with elevated serum TG levels. Conclusions In the current study, elevated serum TG level was found to be an independent predictor of the increased severity of AP, as suggested by higher Ranson scores and adverse clinical outcomes among the patients with raised serum TG levels. This current study supports the use of serum TG level as a reliable tool for the prompt identification of high-risk AP patients, facilitating timely interventions and improved outcomes.

Acute Pancreatitis in Pregnancy and Puerperium: Assessing Maternal and Fetal Impact, Etiologies, and Clinical Outcomes at a Tertiary Care Hospital in Pakistan

Introduction The association of acute pancreatitis with adverse obstetric outcomes remains subject to great controversy. Outcomes are affected by the standard of care available, and hence, will be better in developed countries than in underdeveloped countries like Pakistan. Therefore, this study aimed to understand the clinical characteristics and treatment of acute pancreatitis in pregnancy (APIP) and its associated maternal and neonatal outcomes in a tertiary care hospital in Pakistan. Methodology A retrospective clinical analysis of APIP cases during pregnancy and the postpartum period was conducted at Aga Khan University Hospital (AKUH) in Karachi, Pakistan, from January 1, 2015, to December 31, 2021. Data were collected from the medical records of women diagnosed with APIP. Pregnant women with chronic and recurrent pancreatitis were excluded. We analyzed baseline demographics, obstetric outcomes, and neonatal outcomes for those who delivered at AKUH. These individuals were monitored in postnatal outpatient clinics to track changes in their initial symptoms. Data were analyzed using IBM SPSS version 25.0. Results A total of 32 patients with APIP were included. Among them, 13 (40.6%) were primigravida, and 21 (65.6%) were multigravida. The majority 22 (69%) presented in the third trimester. The most common etiology was gallstones 13 (40.6%), followed by idiopathic causes 12 (37.5%), and hypertriglyceridemia 2 (6.3%). The disease course remained mild in 24 (75%) of patients, moderate in 5 (15.6%), and severe in 3 (9.4%) according to The Atlanta Criteria. Conservative management was successful in 27 (84.4%), while 5 (15.6%) of patients required surgical intervention. Severe disease courses led to organ dysfunction and disseminated intravascular coagulation in 5 (15.6%), and maternal mortality in 3 (9.4%). Preeclampsia was the most common obstetric complication (6 (18.8%)), and 13 (40.6%) patient underwent an emergency cesarean section. In the mild group, one patient experienced miscarriage, and 14 (43.7%) patients preterm births, with 6 (18.8%) of these newborns requiring NICU admissions and 2 (6.3%) experiencing perinatal mortality. In the severe group, 2 (6.3%) had intrauterine fetal demise. Post-delivery, 12 (37.5%) were lost to follow-up. However, among the patients who followed up, 21 (62.5%) experienced an improvement in their general health condition. Conclusions Our study underscores the increased risk of preeclampsia and preterm births in women with APIP, emphasizing the need for heightened vigilance in disease progression and antenatal care.

Construction and validation of a nomogram for predicting survival in elderly patients with severe acute pancreatitis: a retrospective study from a tertiary center

PURPOSE

There is a lack of adequate models specifically designed for elderly patients with severe acute pancreatitis (SAP) to predict the risk of death. This study aimed to develop a nomogram for predicting the overall survival of SAP in elderly patients.

METHODS

Elderly patients diagnosed with SAP between January 1, 2017 and December 31, 2022 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed using multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 326 patients were included in the analysis, with 260 in the survival group and 66 in the deceased group. Multivariate logistic regression indicated that age, respiratory rate, arterial pH, total bilirubin, and calcium were independent prognostic factors for the survival of SAP patients. The nomogram demonstrated a performance comparable to sequential organ failure assessment (P = 0.065). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of elderly patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection

Background

The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.

Methods

This was a secondary analysis of an international observational study ("AbSeS") investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).

Results

The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.

Conclusions

In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.ClinicalTrials.gov number: NCT03270345.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common surgical condition, with severe AP (SAP) potentially lethal. Many prognostic indices, including; acute physiology and chronic health evaluation II score (APACHE II), bedside index of severity in acute pancreatitis (BISAP), Glasgow score, harmless acute pancreatitis score (HAPS), Ranson's score, and sequential organ failure assessment (SOFA) evaluate AP severity and predict mortality.

AIM

To evaluate these indices' utility in predicting severity, intensive care unit (ICU) admission, and mortality.

METHODS

A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed. The demographic, clinical profile, and patient outcomes were collected. SAP was defined as per the revised Atlanta classification. Values for APACHE II score, BISAP, HAPS, and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform. Data with < 10% missing data was imputed via mean substitution. Other patient information such as demographics, disease etiology, and patient outcomes were also derived from electronic medical records.

RESULTS

The mean age was 58.7 ± 17.5 years, with 58.7% males. Gallstones (n = 404, 61.9%), alcohol (n = 38, 5.8%), and hypertriglyceridemia (n = 19, 2.9%) were more common aetiologies. 81 (12.4%) patients developed SAP, 20 (3.1%) required ICU admission, and 12 (1.8%) deaths were attributed to SAP. Ranson's score and APACHE-II demonstrated the highest sensitivity in predicting SAP (92.6%, 80.2% respectively), ICU admission (100%), and mortality (100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP (13.6%, 24.7% respectively), ICU admission (40.0%, 25.0% respectively) and mortality (50.0%, 25.5% respectively). However, SOFA demonstrated the highest specificity in predicting SAP (99.7%), ICU admission (99.2%), and mortality (98.9%). SOFA demonstrated the highest positive predictive value, positive likelihood ratio, diagnostic odds ratio, and overall accuracy in predicting SAP, ICU admission, and mortality. SOFA and Ranson's score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP (0.966, 0.857 respectively), ICU admission (0.943, 0.946 respectively), and mortality (0.968, 0.917 respectively).

CONCLUSION

The SOFA and 48-h Ranson's scores accurately predict severity, ICU admission, and mortality in AP, with more favorable statistics for the SOFA score.

Outcome of patients with acute severe necrotizing pancreatitis in a dedicated hepato-biliary unit of Pakistan

Objective:

To analyze the management of severe necrotizing pancreatitis in a specialized center of a lower middle-income country, Pakistan using multiple outcome measures.

Methods:

All the patients in this prospective observational study with severe necrotizing pancreatitis being referred to Pak Emirates Military Hospital from January 2017 to December 2019 were followed over the course of their admission. Demographic data and disease outcomes were duly noted. Cox regression analysis was used to predict fatality outcome.

Results:

A total of 57 patients with 48 (84.6%) infected necrotizing pancreatitis were managed in our set up. The most common etiology reported was gall-stones (37%) with male preponderance (72%) and a mean age of 50±11.3 years. The most common complications were acute-kidney-injury (63%), splenic-vein-thrombosis (21%) and ascites (21%). Fourteen patients required mechanical-ventilation with a mean duration of 7±1.4 days on respiratory support. Eight (14%) patients required Endoscopic-Ultra-Sound guided drainage and six (10.5%) underwent surgical-necrosectomy depending upon the patients’ condition and collections characteristics. Mortality, as one of the main outcome measures, was reported to be 12.3% and was statistically related to mechanical-ventilation, organ failure and surgical-necrosectomy while 22 (38.6%) patients were discharged on pancreatic enzymes supplements and 7% required insulin.

Conclusion:

Survival outcomes with acute severe necrotizing pancreatitis are improving in a dedicated hepato-biliary unit internationally in lieu with a multidisciplinary team approach. Percutaneous and EUS guided drainage of pancreatic collections have turned out to be an important procedure to manage infected pancreatic necrosis that helps to avoid a morbid procedure in the form of necrosectomy.