The Atlanta Classification of acute pancreatitis revisited

The potential role of BMI, plasma leptin, nesfatin-1 and ghrelin levels in the early detection of pancreatic necrosis and severe acute pancreatitis: a prospective cohort study

BACKGROUND

Early prediction of disease severity in acute pancreatitis (AP) is crucial. The aim of this study was to investigate the body-mass index (BMI), plasma leptin, nesfatin-1 and ghrelin levels as potential markers predicting peripancreatic necrosis and severity in acute pancreatitis.

METHODS

In the study period, 97 consecutive patients with AP were prospectively analysed. Severe AP was defined according to the Atlanta Criteria. BMI was also calculated. To measure plasma Leptin, Nesfatin-1 and Ghrelin concentrations, the blood samples were obtained from patients within 24 hours of admission.

RESULTS

Out of 97 patients, 92(70 females, 22 males) were considered eligible for analysis. Of the 92 patients, 30 patients (32.6%) were assessed as severe pancreatitis. BMI and leptin levels were significantly higher in patients with severe pancreatitis. The pooled sensitivity and specificity of BMI as a predictor for the development of pancreatic necrosis were 0.90(95%CI = 0.56-0.99) and 0.70(95%CI = 0.58-0.79), respectively; with an overall area under curve value of 0.78.The pooled sensitivity and specificity of leptin levels as a predictor for development of pancreatic necrosis were 1(95%CI = 0.69-1) and 0.73(95%CI = 0.62-0.82),respectively; with an overall area under curve value of 0.82.Nesfatin-1 and ghrelin levels showed no significant difference in patients with mild pancreatitis (6.97 ± 0.84 ng/ml and 2.3(1.0-9.9);respectively) and severe pancreatitis (6.74 ± 0.65 ng/ml and 2.0(1.9-9.9); respectively) (p = 0.1923 and 0.8531;respectively).

CONCLUSION

BMI and plasma leptin levels both were correlated with the severity of pancreatitis. Leptin levels showed better area under the curve, sensitivity and specificity values compared to BMI in prediction of pancreatic necrosis.Nesfatin-1 and ghrelin levels were not found to be predictors of the severity of disease.

Natural resolution or intervention for fluid collections in acute severe pancreatitis

BACKGROUND

Revisions in terminology of fluid collections in acute pancreatitis have necessitated reanalysis of their evolution and outcome. The course of fluid collections in patients with acute pancreatitis was evaluated prospectively.

METHODS

Consecutive adults with acute pancreatitis, who had contrast-enhanced CT (CECT) within 5-7 days of symptom onset, were enrolled in a prospective cohort study in a tertiary-care centre. Patients were treated according to standard guidelines. Follow-up transabdominal ultrasonography was done at 4-week intervals for at least 6 months. CECT was repeated at 6-10 weeks, or at any time if there were new or persistent symptoms. Asymptomatic collections were followed until spontaneous resolution. Risk factors for pancreatic pseudocysts or walled-off necrosis (WON) were assessed in multivariable analyses.

RESULTS

Of 122 patients with acute pancreatitis, 109 were analysed. Some 91 patients (83·5 per cent) had fluid collections at baseline. Eleven of 29 with interstitial oedematous pancreatitis had acute peripancreatic fluid collections, none of which evolved into pseudocysts. All 80 patients with acute necrotizing pancreatitis had at least one acute necrotizing collection (ANC); of these, five patients died (2 after drainage), three underwent successful drainage within 5 weeks, and collections resolved spontaneously in 33 and evolved into WON in 39. By 6 months' follow-up, WON had required drainage in eight patients, resolved spontaneously in 23 and was persistent but asymptomatic in seven. Factors associated with increased risk of WON were blood urea nitrogen 20 mg/dl or more (odds ratio (OR) 10·96, 95 per cent c.i. 2·57 to 46·73; P = 0·001) and baseline ANC diameter greater than 6 cm (OR 14·57, 1·60 to 132·35; P = 0·017). Baseline ANC diameter over 6 cm was the only independent predictor of either the need for drainage or persistence of such collections beyond 6 months (hazard ratio 6·61, 1·77 to 24·59; P = 0·005).

CONCLUSION

Pancreatic pseudocysts develop infrequently in oedematous acute pancreatitis. Only one-quarter of ANCs either require intervention or persist beyond 6 months, whereas more than one-half of WONs resolve without any intervention within 6 months of onset. Baseline diameter of ANC(s) is an important predictor of outcome.

Retrocrural space involvement on computed tomography as a predictor of mortality and disease severity in acute pancreatitis

Background

Because computed tomography (CT) has advantages for visualizing the manifestation of necrosis and local complications, a series of scoring systems based on CT manifestations have been developed for assessing the clinical outcomes of acute pancreatitis (AP), including the CT severity index (CTSI), modified CTSI, etc. Despite the internationally accepted CTSI having been successfully used to predict the overall mortality and disease severity of AP, recent literature has revealed the limitations of the CTSI. Using the Delphi method, we establish a new scoring system based on retrocrural space involvement (RCSI), and compared its effectiveness at evaluating the mortality and severity of AP with that of the CTSI.

Methods

We reviewed CT images of 257 patients with AP taken within 3–5 days of admission in 2012. The RCSI scoring system, which includes assessment of infectious conditions involving the retrocrural space and the adjacent pleural cavity, was established using the Delphi method. Two radiologists independently assessed the RCSI and CTSI scores. The predictive points of the RCSI and CTSI scoring systems in evaluating the mortality and severity of AP were estimated using receiver operating characteristic (ROC) curves.

Principal Findings

The RCSI score can accurately predict the mortality and disease severity. The area under the ROC curve for the RCSI versus CTSI score was 0.962±0.011 versus 0.900±0.021 for predicting the mortality, and 0.888±0.025 versus 0.904±0.020 for predicting the severity of AP. Applying ROC analysis to our data showed that a RCSI score of 4 was the best cutoff value, above which mortality could be identified.

Conclusion

The Delphi method was innovatively adopted to establish a scoring system to predict the clinical outcome of AP. The RCSI scoring system can predict the mortality of AP better than the CTSI system, and the severity of AP equally as well.

Treatment options for acute pancreatitis

This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.

Classifications of acute pancreatitis: to Atlanta and beyond

Until Atlanta Classification (AC) made in 1992, there was not any classification of acute pancreatitis (AP). Last twenty years AC let us compare results and papers. But the increasing understanding of the pathophysiology of AP, improvements in diagnostic methods and the development of minimally invasive tools for radiological, endoscopic and surgical management of local complications, several authors have called for the AC to be reviewed. Last months, two new classifications of AP have been published. We made a historical review of AC, the two new classifications and a comparison between them.

Clinical utility of the revised Atlanta classification of acute pancreatitis in a prospective cohort: have all loose ends been tied?

BACKGROUND AND AIM

Revision of the Atlanta classification for acute pancreatitis (AP) was long awaited. The Revised Atlanta Classification has been recently proposed. In this study, we aim to prospectively evaluate and validate the clinical utility of the new definitions.

PATIENT AND METHODS

163 consecutive patients with AP were followed till death/6 mths after discharge. AP was categorized as mild (MAP) (no local complication[LC] and organ failure[OF]), moderate (MSAP)(transient OF and/or local/systemic complication but no persistent OF) and severe (SAP) AP (persistent OF). LC included acute peripancreatic fluid collections, pseudocyst, acute necrotic collection, walled-off necrosis, gastric outlet dysfunction, splenic/portal vein thrombosis, and colonic necrosis. Baseline characteristics (age/gender/hematocrit/BUN/SIRS/BISAP) and outcomes (total hospital stay/need for ICU care/ICU days/primary infected (peri)pancreatic necrosis[IN]/in-hospital death) were compared.

RESULTS

43 (26.4%) patients had ANP, 87 (53.4%) patients had MAP, 58 (35.6%) MSAP and 18 (11.04%) SAP. Among the baseline characteristics, BISAP score was significantly higher in MSAP compared to MAP [1.6 (1.5-2.01) vs 1.2 (1.9-2.4); p = 0.002]; and BUN was significantly higher in SAP compared to MSAP[64.9 (50.7-79.1) vs 24.9 (20.7-29.1); p < 0.0001]. All outcomes except mortality were significantly higher in MSAP compared to MAP. Need for ICU care (83.3%vs43.1%; p = 0.01), total ICU days[7.9 (4.8-10.9) vs 3.5 (2.7-5.1); p = 0.04] and mortality (38.9%vs1.7%; p = 0.0002) was significantly more in SAP compared to MSAP. 8/18 (44.4%) patients had POF within seven days of disease onset (early OF). This was associated with 37.5% of total in-hospital mortality. Patients with MSAP who had primary IN (n = 10) had similar outcomes as SAP.

CONCLUSIONS

This study prospectively validates the clinical utility of the Revised Atlanta definitions of AP. However, MSAP patients with primary infected necrosis may behave as SAP. Furthermore, patients with early severe acute pancreatitis (early OF) could represent a subgroup that needs to be dealt with separately in classification systems.

Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification

BACKGROUND

Recent international multidisciplinary consultation proposed the use of local (sterile or infected pancreatic necrosis) and/or systemic determinants (organ failure) in the stratification of acute pancreatitis. The present study was to validate the moderate severity category by international multidisciplinary consultation definitions.

METHODS

Ninety-two consecutive patients with severe acute pancreatitis (according to the 1992 Atlanta classification) were classified into (i) moderate acute pancreatitis group with the presence of sterile (peri-) pancreatic necrosis and/or transient organ failure; and (ii) severe/critical acute pancreatitis group with the presence of sterile or infected pancreatic necrosis and/or persistent organ failure. Demographic and clinical outcomes were compared between the two groups.

RESULTS

Compared with the severe/critical group (n=59), the moderate group (n=33) had lower clinical and computerized tomographic scores (both P<0.05). They also had a lower incidence of pancreatic necrosis (45.5% vs 71.2%, P=0.015), infection (9.1% vs 37.3%, P=0.004), ICU admission (0% vs 27.1%, P=0.001), and shorter hospital stay (15+/-5 vs 27+/-12 days; P<0.001). A subgroup analysis showed that the moderate group also had significantly lower ICU admission rates, shorter hospital stay and lower rate of infection compared with the severe group (n=51). No patients died in the moderate group but 7 patients died in the severe/critical group (4 for severe group).

CONCLUSIONS

Our data suggest that the definition of moderate acute pancreatitis, as suggested by the international multidisciplinary consultation as sterile (peri-) pancreatic necrosis and/or transient organ failure, is an accurate category of acute pancreatitis.

Comparison of the BISAP scores for predicting the severity of acute pancreatitis in Chinese patients according to the latest Atlanta classification

BACKGROUND

The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic multifactor scoring system. As there were no studies designed to validate this system according to the latest Atlanta classification in China and more data are needed before clinical application, we compared BISAP, the Acute Physiology and Chronic Health Evaluation (APACHE) II and Ranson scoring systems in predicting the severity, pancreatic necrosis and mortality of acute pancreatitis (AP) using the latest 2012 Atlanta classification in a tertiary care center in China.

METHODS

The medical records of all patients with AP admitted to our hospitals between January 2010 and June 2013 were reviewed retrospectively. Severe AP was defined as the persistence of organ failure for more than 48 h. The capacity of the BISAP, APACHE II and Ranson's score system to predict severity, pancreatic necrosis and mortality was evaluated using linear-by-linear association. The predictive accuracy of the BISAP, APACHE II and Ranson's score was measured as the area under the receiver operating characteristic curve (AUC).

RESULTS

Of 155 patients enrolled in the study, 16.7% were classified as having severe AP, and six (3.2%) died. There were statistically significant trends for increasing severity (P < 0.001), PNec (P < 0.001) and mortality (P < 0.001) with increasing BISAP. The AUC for severity predicted by BISAP was 0.793 (95% confidence interval [CI] 0.700-0.886), APACHE II 0.836 (95% CI 0.744-0.928) and by Ranson score was 0.903 (95% CI 0.814-0.992). The AUC for PNec predicted by BISAP was 0.834 (95% CI 0.739-0.929), APACHE II 0.801 (95% CI 0.691-0.910) and by Ranson score was 0.840 (95% CI 0.741-0.939). The AUC for mortality predicted by BISAP was 0.791 (95% CI 0.593-0.989), APACHE II 0.812 (95% CI 0.717-0.906) and by Ranson score was 0.904 (95% CI 0.829-0.979).

CONCLUSIONS

BISAP score may be a valuable source for risk stratification and prognostic prediction in Chinese patients with AP. A prospective and multicenter validation study is required to confirm our results and further our recognition of BISAP scores in AP.

Does the presence of obesity and/or metabolic syndrome affect the course of acute pancreatitis?: A prospective study

OBJECTIVE

The incidence of acute pancreatitis (AP) is rising with increased prevalence of obesity, which exacerbates pancreatic injury. Metabolic syndrome (MS) is defined as a cluster condition of cardiovascular risk factors, including hyperglycemia, dyslipidemia, hypertension, and central obesity. We analyze if the presence of obesity and/or MS affects the course of pancreatitis.

METHODS

Data were collected from 140 patients with AP between January 2010 and February 2013. Anthropometric data, including body mass index and waist circumference, were measured. Biochemical tests were used including fasting glucose, triglyceride, low- and high-density lipoprotein cholesterol levels, and total cholesterol level. Atlanta criteria, Acute Physiology and Chronic Health Evaluation II, and Ranson scoring system were used to define severe AP. Patients were classified as having MS based on the International Diabetic Federation criteria.

RESULTS

The mean body mass index was 30.15 kg/m(2). Sixteen (11.4%) patients had severe AP, whereas 124 (88.6%) patients had mild AP. We found that 62.8% of patients with AP fulfilled the criteria of MS (P = 0.000). Body weight can be used to predict clinical severity of AP with significant P value (P = 0.009).

CONCLUSIONS

The presence of MS in patients with pancreatitis is noticeable, but it does not affect the course of disease severity, whereas obesity correlates with pancreatitis severity.

Effects of intensive insulin therapy combined with low molecular weight heparin anticoagulant therapy on severe pancreatitis

The current study explored the effects of intensive insulin therapy (IIT) combined with low molecular weight heparin (LMWH) anticoagulant therapy on severe acute pancreatitis (SAP). A total of 134 patients with SAP that received treatment between June 2008 and June 2012 were divided randomly into groups A (control; n=33), B (IIT; n=33), C (LMWH; n=34) and D (IIT + LMWH; n=34). Group A were treated routinely. Group B received continuous pumped insulin, as well as the routine treatment, to maintain the blood sugar level between 4.4 and 6.1 mmol/l. Group C received a subcutaneous injection of LMWH every 12 h in addition to the routine treatment. Group D received IIT + LMWH and the routine treatment. The white blood cell count, hemodiastase, serum albumin, arterial partial pressure of oxygen and prothrombin time were recorded prior to treatment and 1, 3, 5, 7 and 14 days after the initiation of treatment. The intestinal function recovery time, incidence rate of multiple organ failure (MOF), length of hospitalization and fatality rates were observed. IIT + LMWH noticeably increased the white blood cell count, hemodiastase level, serum albumin level and the arterial partial pressure of oxygen in the patients with SAP (P<0.05). It markedly shortened the intestinal recovery time and the length of stay and reduced the incidence rate of MOF, the surgery rate and the fatality rate (P<0.05). It did not aggravate the hemorrhagic tendency of SAP (P>0.05). IIT + LMWH had a noticeably improved clinical curative effect on SAP compared with that of the other treatments.

Farnesyltransferase regulates neutrophil recruitment and tissue damage in acute pancreatitis

OBJECTIVES

The signaling mechanisms controlling organ damage in the pancreas in severe acute pancreatitis (AP) remain elusive. Herein, we examined the role of farnesyltransferase signaling in AP.

METHODS

Pancreatitis was provoked by the infusion of taurocholate into the pancreatic duct in C57BL/6 mice. Animals were treated with a farnesyltransferase inhibitor FTI-277 (25 mg/kg) before pancreatitis induction.

RESULTS

FTI-277 decreased the blood amylase levels, pancreatic neutrophil infiltration, hemorrhage, and edema formation in the pancreas in mice challenged with taurocholate. Farnesyltransferase inhibition reduced the myeloperoxidase levels in the pancreas and lungs in response to taurocholate infusion. However, FTI-277 had no effect on the taurocholate-provoked formation of macrophage inflammatory protein-2 in the pancreas. Interestingly, farnesyltransferase inhibition abolished the neutrophil expression of macrophage-1 antigen in mice with pancreatitis. In addition, FTI-277 decreased the taurocholate-induced activation of the rat sarcoma protein in the pancreas. An important role of farnesyltransferase was confirmed in L-arginine-induced pancreatitis.

CONCLUSIONS

These results demonstrate that farnesyltransferase signaling plays a significant role in AP by regulating neutrophil infiltration and tissue injury via the neutrophil expression of macrophage-1 antigen. Thus, our findings not only elucidate novel signaling mechanisms in pancreatitis but also suggest that farnesyltransferase might constitute a target in the management of severe AP.

Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience

Multidetector-row computed tomography (MDCT) and magnetic resonance (MR) imaging are currently the most frequently performed imaging modalities for the study of pancreatic disease. In cases of suspected autoimmune pancreatitis (AIP), a dynamic quadriphasic (precontrast, contrast-enhanced pancreatic, venous and late phases) study is recommended in both techniques. In the diffuse form of autoimmune pancreatitis (DAIP), the pancreatic parenchyma shows diffuse enlargement and appears, during the MDCT and MR contrast-enhanced pancreatic phase, diffusely hypodense and hypointense, respectively, compared to the spleen because of lymphoplasmacytic infiltration and pancreatic fibrosis. During the venous phase of MDCT and MR imaging, the parenchyma appears hyperdense and hyperintense, respectively, in comparison to the pancreatic phase. In the delayed phase of both imaging modalities, it shows retention of contrast media. A "capsule-like rim" may be recognised as a peripancreatic MDCT hyperdense and MR hypointense halo in the T2-weighted images, compared to the parenchyma. DAIP must be differentiated from non-necrotizing acute pancreatitis (NNAP) and lymphoma since both diseases show diffuse enlargement of the pancreatic parenchyma. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT has an important role. In the focal form of autoimmune pancreatitis (FAIP), the parenchyma shows segmental enlargement involving the head, the body-tail or the tail, with the same contrast pattern as the diffuse form on both modalities. FAIP needs to be differentiated from pancreatic adenocarcinoma to avoid unnecessary surgical procedures, since both diseases have similar clinical and imaging presentation. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT and MR imaging both have an important role. MR cholangiopancreatography helps in the differential diagnosis. Furthermore, MDCT and MR imaging can identify the extrapancreatic manifestations of AIP, most commonly biliary, renal and retroperitoneal. Finally, in all cases of uncertain diagnosis, MDCT and/or MR follow-up after short-term treatment (2-3 weeks) with high-dose steroids can identify a significant reduction in size of the pancreatic parenchyma and, in FAIP, normalisation of the calibre of the upstream main pancreatic duct.

Analysis of the Power of Common Diagnostic Tools in the Management of Acute Pancreatitis

Acute pancreatitis (AP) is a serious medical condition usually associated with severe upper abdominal pain. The purpose of our study is to assess the therapeutic consequences of contrast-enhanced computed tomography (CE-CT) and the predictive value of CRP for severe pancreatitis. We included patients with a threefold increase of plasma lipase who had received a CE-CT or had a CRP of =150 mg/dl. A total of 74 out of 283 patients got a contrast-enhanced CT scan; in 11 cases the CT was followed by endoscopic or surgical interventions as therapeutic consequences compared with 19 out of 50 control cases. 69 out of 283 patients (24,3%) had CRP >150 mg/dl within 48 hours after admission. 32 of them had SAP. The CRP cutoff of 150 mg/L had a sensitivity of 80% and a specificity of 65%. The positive predictive value for SAP in patients beyond the cutoff is 46.4%. The negative predictive value for SAP in patients below the cutoff was 89.5%. Our results support the opinion that an early CE-CT is usually not indicated. CRP helps to assess the course of AP; levels below 150 mg/dl between the first 48 h indicate a mild course in most of the cases.

Procalcitonin levels predict acute kidney injury and prognosis in acute pancreatitis: a prospective study

Background

Acute kidney injury (AKI) has been proposed as a leading cause of mortality for acute pancreatitis (AP) patients admitted to the intensive care unit (ICU). This study investigated the predictive value of procalcitonin (PCT) for AKI development and relevant prognosis in patients with AP, and compared PCT’s predictive power with that of other inflammation-related variables.

Methods

Between January 2011 and March 2013, we enrolled 305 cases with acute pancreatitis admitted to ICU. Serum levels of PCT, serum amyloid A (SAA), interleukin-6 (IL-6), and C reactive protein (CRP) were determined on admission. Serum PCT was tested in patients who developed AKI on the day of AKI occurrence and on either day 28 after occurrence (for survivors) or on the day of death (for those who died within 28 days).

Results

Serum PCT levels were 100-fold higher in the AKI group than in the non-AKI group on the day of ICU admission (p<0.05). The area under the receiver-operating characteristic (ROC) curve of PCT for predicting AKI was 0.986, which was superior to SAA, CRP, and IL-6 (p<0.05). ROC analysis revealed all variables tested had lower predictive performance for AKI prognosis. The average serum PCT level on day 28 (2.67 (0.89, 7.99) ng/ml) was significantly (p<0.0001) lower than on the day of AKI occurrence (43.71 (19.24,65.69) ng/ml) in survivors, but the serum PCT level on death (63.73 (34.22,94.30) ng/ml) was higher than on the day of AKI occurrence (37.55 (18.70,74.12) ng/ml) in non-survivors, although there was no significant difference between the two days in the latter group (p = 0.1365).

Conclusion

Serum PCT is superior to CRP, IL-6, and SAA for predicting the development of AKI in patients with AP, and also can be used for dynamic evaluation of AKI prognosis.

Endoscopic transmural drainage of pancreatic pseudocysts: technical challenges in the resource poor setting

Although surgical drainage of pancreatic pseudocysts has been superseded by less invasive options, the requirement for specialized equipment, technical expertise, and consumables limits the options available in low resource settings. We describe the challenges experienced during endoscopic transmural drainage in a low resource setting and the methods used to overcome these barriers. Despite operating in a low resource environment, endoscopic drainage of pancreatic pseudocysts can be incorporated into our armamentarium with minimal change to the existing hardware. Careful patient selection by a dedicated multidisciplinary team should be observed in order to achieve good outcomes.

Staged multidisciplinary step-up management for necrotizing pancreatitis

Background

Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services.

Methods

This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease.

Results

Frequent clinical evaluation of the patient's condition remains paramount in the first 24–72 h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine-needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary ‘step-up’ approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become ‘walled-off’.

Conclusion

Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach.

An evidence-based proposal for predicting organ failure in severe acute pancreatitis

OBJECTIVES

Early, efficient, and accurate evaluation for organ failure is an important step for improving outcome in severe acute pancreatitis (SAP). We aim to develop a method that can early, efficiently, and accurately evaluate the in-hospital organ failure in patients with SAP.

METHODS

Using multivariate logistic regression analysis, the associative factors for in-hospital organ failure were evaluated retrospectively from conventional data obtained from 393 patients with SAP from 2000 to 2012. In classification and regression tree analysis, a new clinical scoring system was developed for the evaluation of in-hospital organ failure in SAP. We also compared the accuracy of our new scoring system with multiple organ dysfunction score and Acute Physiology and Chronic Health Examination II score by the receiver operating characteristic curve.

RESULTS

Laboratory results revealed serum calcium level greater than or equal to 1.84 mmol/L, serum creatinine level greater than or equal to 110 µmol/L, age greater than or equal to 72 years, activated partial thromboplastin time less than or equal to 30.95 seconds, and Balthazar computed tomography score greater than or equal to 7 (CCAAB) score system, each contributed 1 point for the prediction of organ failure. The area under the curve of the CCAAB score system was similar to multiple organ dysfunction scores and Acute Physiology and Chronic Health Examination II scores.

CONCLUSIONS

The new scoring system CCAAB is an efficient and accurate method for the early evaluation of patients with SAP for in-hospital organ failure.

Endoscopic therapy of necrotizing pancreatitis and pseudocysts

Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.

Failure to follow evidence-based best practice guidelines in the treatment of severe acute pancreatitis

OBJECTIVES

Evidence-based guidelines for the treatment of severe acute pancreatitis have been established. This study was conducted to investigate the hypothesis that deviation from guidelines occurs frequently.

METHODS

With institutional review board approval, the outside medical records of patients with severe pancreatitis who were transferred to the study institution during the period from July 2005 to May 2012 were reviewed. Severe pancreatitis was defined using the Atlanta Classification criteria. Records were reviewed with respect to published guidelines defining the appropriate use of imaging, antibiotics and nutritional support.

RESULTS

A total of 538 patients with acute pancreatitis were identified. Of 67 patients with severe acute pancreatitis, 44 (66%) were male. The mean age of the patients was 55 years. Forty-five of 61 (74%) patients for whom relevant data were available were imaged upon admission, but only 15 (31%) patients were imaged appropriately by computerized tomography with i.v. contrast to assess the presence of necrosis or other complications. In patients for whom relevant data were available, prophylactic antibiotics were initiated in the absence of culture data or a specific infectious target in 26 (53%) patients. Total parenteral nutrition (TPN) was administered to 38 (60%) of 63 patients for whom relevant data were available; only 10 (17%) patients received enteric feeding. No nutritional support was provided to 15 (23%) patients.

CONCLUSIONS

Adherence to best practice guidelines in the treatment of severe pancreatitis is poor. The consistent application of current knowledge might improve outcomes in these patients.

The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines

Imaging of acute pancreatitis requires not only an understanding of the disease subtypes and the myriad of associated complications but also familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, by the Acute Pancreatitis Classification Working Group in 2008. The accurate description of the radiological findings plays a critical role in the evaluation and management of patients with acute pancreatitis, particularly those with severe disease. There have been increasing efforts to develop uniformity in the use of terminology used to define the radiologic findings in acute pancreatitis, in particular, the terminology for fluid collections, a common area of inconsistency and confusion. Terms such as "acute peripancreatic fluid collections," "acute post- necrotic fluid collections," "pseudocyst," and "walled-off pancreatic necrosis" are now recommended as they describe the evolution of fluid collections in patients with both interstitial and necrotizing pancreatitis and nonspecific terms such as "pancreatic abscess" and "phlegmon" are being abandoned. In this review we illustrate, with case examples, the standardized terminology used in the radiological and clinical description of acute pancreatitis, its severity, and complications with an emphasis on the role of ultrasound, computed tomography and magnetic resonance imaging. Different management options of the associated complications are also discussed. The use of standardized terminology will hopefully improve the communication between radiologists, gastroenterologists, and surgeons to facilitate treatment planning and will lead to enhanced outcomes for patients with acute pancreatitis as well as create uniformity for enrollment into research studies.

Intra-abdominal pressure in the early phase of severe acute pancreatitis: canary in a coal mine? Results from a rigorous validation protocol

Background/Aims

Intra-abdominal hypertension (IAH) is being increasingly reported in patients with severe acute pancreatitis (SAP) with worsened outcomes. The present study was undertaken to evaluate intra-abdominal pressure (IAP) as a marker of severity in the entire spectrum of acute pancreatitis and to ascertain the relationship between IAP and development of complications in patients with SAP.

Methods

IAP was measured via the transvesical route by measurements performed at admission, once after controlling pain and then every 4 hours. Data were collected on the length of the hospital stay, the development of systemic inflammatory response syndrome (SIRS), multiorgan failure, the extent of necrosis, the presence of infection, pleural effusion, and mortality.

Results

In total, 40 patients were enrolled and followed up for 30 days. The development of IAH was exclusively associated with SAP with an APACHE II score ≥8 and/or persistent SIRS, identifying all patients who were going to develop abdominal compartment syndrome (ACS). The presence of ACS was associated with a significantly increased extent of pancreatic necrosis, multiple organ failure, and mortality. The mean admission IAP value did not differ significantly from the value obtained after pain control or the maximum IAP measured in the first 5 days.

Conclusions

IAH is reliable marker of severe disease, and patients who manifest organ failure, persistent SIRS, or an Acute Physiology and Chronic health Evaluation II score ≥8 should be offered IAP surveillance. Severe pancreatitis is not a homogenous entity.

Dynamic nature of organ failure in severe acute pancreatitis: the impact of persistent and deteriorating organ failure

BACKGROUND AND AIMS

In acute pancreatitis (AP), patients with persistent organ failure [POF, duration of organ failure (OF) ≥48 h] and transient organ failure (TOF, duration of OF <48 h) have different outcomes. We have compared the clinical course and outcome of patients with severe AP (SAP) with TOF and POF in the first week of hospitalization as well as the impact of change in the OF score in the first week on patient outcome.

METHODS

Consecutive patients with SAP were evaluated for OF and its dynamics during the first week of hospitalization. The modified multiple organ failure score (MOFS) was used to identify OF, grade its severity and monitor its progression. The clinical course and outcome of patients were studied.

RESULTS

Of 114 patients, mean age 39.2 ± 13.7 years, 37 (32.5%) patients had no OF, 34 (29.8%) had TOF and 43(37.7%) had POF. Patients with POF had the higher infected necrosis, increased requirement for percutaneous drain placement, surgery and higher mortality as compared with those with TOF. The odds ratio for mortality with persistent and deteriorating OF was 26.2 [confidence interval (CI) 5.1-134.9] compared with only persistent OF.

CONCLUSION

The dynamics of OF in the first week of SAP predicts the clinical course and outcome. Persistent and deteriorating OF indicates a poor outcome.

[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]

OBJECTIVE

To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation.

BACKGROUNDS

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity.

METHODS

A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Association of endotoxin and endothelin-1 with acute kidney injury in patients with acute pancreatitis

AIM: To investigate the association of endotoxin and endothelin-1 with acute kidney injury in patients with acute pancreatitis (AP).

METHODS: Fifty-two AP patients with acute kidney injury and equal number of AP patients without acute kidney injury were enrolled in this study. Blood samples were obtained from all patients for laboratory analysis of liver function, renal function, electrolytes, procalcitonin (PCT) and endothelin-1 (ET-1).

RESULTS: The SIRS score showed no significant difference between cases and controls (2.66 ± 0.86 vs 2.30 ± 1.00, t = 1.90, P > 0.05), indicating that both groups suffered from systemic inflammatory response. The levels of PCT (23.24 ng/mL vs 0.23 ng/mL, Z = -7.31, P < 0.05) , ET-1 (7.61 pg/mL ± 2.17 pg/mL vs 2.34 pg/mL ± 1.28 pg/mL, t = 4.98, P < 0.05), urea (Z = -2.17), creatinine (Z = -7.69) and cystatin C (Z = -8.39) were significantly higher in cases than in controls. The mortality and improvement rates also differed significantly between cases and controls (36.5% vs 5.8%; 21.2% vs 94.2%, χ² = 141.92, P < 0.05).

CONCLUSION: Endotoxin and ET-1 are closely associated with the development of acute kidney injury possibly by inducing severe renal vasoconstriction.

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.

Usefulness of the Bedside Index for severity in acute pancreatitis in the early prediction of severity and mortality in acute pancreatitis

OBJECTIVES

The aim of this study was to evaluate the usefulness of the Bedside Index for Severity in Acute Pancreatitis (BISAP) in the early prediction of severity and mortality in AP.

METHODS

The medical records of all patients with acute pancreatitis (AP) admitted to our institution between January 2008 and July 2010 were reviewed retrospectively. Severe AP was defined as the persistence of organ failure for more than 48 hours. The capacity of the BISAP score to predict severity and death was evaluated using linear-by-linear association. The predictive accuracy of the BISAP and Ranson score was measured as the area under the receiver operating characteristic curve (AUC).

RESULTS

Of 299 consecutive patients, 22 (7.4%) were classified as having severe AP, and 8 (2.7%) died. There were statistically significant trends for increasing severity (P < 0.001) and mortality (P < 0.001) with increasing BISAP. The AUC for severity predicted by BISAP was 0.762 (95% confidence interval, 0.631-0.893) and by Ranson score was 0.804 (0.717-0.892). The AUC for mortality predicted by BISAP was 0.940 (0.863-1.018) and by Ranson score was 0.861 (0.734-0.988).

CONCLUSIONS

We confirmed that BISAP is an accurate means of risk stratification in AP within 24 hours of presentation.

High rates of recurrent biliary tract obstruction in children with sickle cell disease

BACKGROUND

Individuals with sickle cell disease (SCD) have an increased risk of cholelithiasis from bilirubin stones. Symptomatic biliary tract disease (BTD) includes acute and chronic cholecystitis, obstruction of the common bile duct (CBD), cholangitis, and gallstone pancreatitis. Cholecystectomy is the main treatment strategy for symptomatic patients; however, the prevalence of recurrent BTD following cholecystectomy has not been systematically evaluated. We conducted a retrospective cohort study to describe the recurrence of BTD after cholecystectomy and characterize risk factors for recurrent disease.

PROCEDURE

We identified patients <22 years of age who presented to the Johns Hopkins Children Center with symptomatic BTD from July 1993 to June 2008.

RESULTS

We identified 56 patients with a total of 76 episodes of symptomatic BTD (median age at first event 15.9, range 4.6-21.5 years). Eleven of the 56 patients (19.6%) had at least one episode of recurrent symptomatic BTD (median follow-up of 5.3 years). Baseline characteristics were similar between the patients with a single episode of BTD and those with recurrent BTD.

CONCLUSIONS

These results demonstrate that recurrent BTD is a frequent complication of SCD (20% by age 4 years) and often presents as CBD obstruction by stone, despite cholecystectomy. In our cohort, recurrence was not associated with age at first episode, baseline total bilirubin, gender, or genotype of SCD.

The new revised classification of acute pancreatitis 2012

This study aims to update the 1991 Atlanta Classification of acute pancreatitis, to standardize the reporting of and terminology of the disease and its complications. Important features of this classification have incorporated new insights into the disease learned over the last 20 years, including the recognition that acute pancreatitis and its complications involve a dynamic process involving two phases, early and late. The accurate and consistent description of acute pancreatitis will help to improve the stratification and reporting of new methods of care of acute pancreatitis across different practices, geographic areas, and countries.

Severe hypertriglyceridemia-related acute pancreatitis

Acute pancreatitis is a potentially life-threatening complication of severe hypertriglyceridemia. In some cases, inborn errors of metabolism such as lipoprotein lipase deficiency, apoprotein C-II deficiency, and familial hypertriglyceridemia have been reported as causes of severe hypertriglyceridemia. More often, severe hypertriglyceridemia describes various clinical conditions characterized by high plasma levels of triglycerides (>1000 mg/dL), chylomicron remnants, or intermediate density lipoprotein like particles, and/or chylomicrons. International guidelines on the management of acute pancreatitis are currently available. Standard therapeutic measures are based on the use of lipid-lowering agents (fenofibrate, gemfibrozil, niacin, Ω-3 fatty acids), low molecular weight heparin, and insulin in diabetic patients. However, when standard medical therapies have failed, non-pharmacological approaches based upon the removal of triglycerides with therapeutic plasma exchange can also provide benefit to patients with severe hypertriglyceridemia and acute pancreatitis. Plasma exchange could be very helpful in reducing triglycerides levels during the acute phase of hyperlipidemic pancreatitis, and in the prevention of recurrence. The current evidence on management of acute pancreatitis and severe hypertriglyceridemia, focusing on symptoms, treatment and potential complications is reviewed herein.

Parenteral analgesics for pain relief in acute pancreatitis: a systematic review

AIM

To assess the efficiency and safety of parenteral analgesics for pain relief in acute pancreatitis.

MATERIALS AND METHODS

We carried out an electronic search of PubMed, Cochrane Library, EMBASE, WEIPU, CNKI and CBM and a manual search for eligible studies. The methodological quality of included trials and quality of evidence were examined by the Cochrane Collaboration's tool for assessing risk of bias and GRADE, respectively. The data were mainly analyzed descriptively and some were pooled by Review manager 5.

RESULTS

Eight randomized controlled trials with a total of 356 patients were finally included in this systematic review. Compared with procaine, pentazocine led to lower pain severity: day 1, Mean Difference (MD), 95%CI: 40.0 [35.3, 44.7]; day 2, MD, 95%CI: 24.00 [20.88, 27.12]; day 3, MD, 95%CI: 5.00 [2.17, 7.83], and it decreased the requirement for additional analgesics, Relative Risk, 95%CI: 2.23 [1.63, 3.05]. The combination of fentanyl, atropine, droperidol and lidocaine rendered lower pain score: day 1, MD, 95%CI: -5.46 [-6.95, -3.97]; day 2, MD, 95%CI: -5.78 [-7.39, -4.17]. Patients treated with metamizole tended to had lower pain than those treated with morphine, MD, 95%CI: -2.60 [-2.95, -2.25]. Nausea, emesis and vomiting were the common adverse events reported and there was almost no significant difference between different agents on safety.

CONCLUSIONS

The systemic review showed that the randomized controlled trials comparing different analgesics were of low quality and did not favor clearly any particular analgesic for pain relief in acute pancreatitis.

The Role of IL-6, 8, and 10, sTNFr, CRP, and Pancreatic Elastase in the Prediction of Systemic Complications in Patients with Acute Pancreatitis

Background and Aim. Early assessment of severity in acute pancreatitis (AP) is a key measure to provide rational and effective management. The aim of our study is to determine the prognostic value of interleukins (IL) 6, 8, and 10, soluble receptor for tumor necrosis factor (sTNFr), pancreatic elastase (E1), and C-reactive protein (CRP) as predictors of systemic complications in AP. Patients and Methods. A hundred and fifty patients with confirmed AP were enrolled in the study. The severity of AP was defined according to Atlanta criteria. Measurements of interleukins and sTNFr were performed on the first day of admission. CRP and E1 levels were assessed on admission and after 48 hours. ROC analysis was performed for all parameters. Results. Interleukins and sTNFr significantly differentiated patients with systemic complications from those without. Elevation of IL-6 showed the highest significance as a predictor (P = 0.001). CRP and elastase levels did not differ between mild and severe cases on admission, but reached statistical significance when measured on the third day (P = 0.002 and P = 0.001, resp.). Conclusion. Our study confirmed that IL-6, IL-8, IL-10, and sTNFr measured on admission, and CRP and pancreatic elastase measured on third day of admission represent valuable prognostic factors of severity and systemic complications of AP.

High-dose versus low-dose octreotide in the treatment of acute pancreatitis: a randomized controlled trial

To evaluate the therapeutic efficacy of high-dose octreotide in patients with predicted severe acute pancreatitis (SAP) or SAP, two hundred and thirty-six patients with predicted SAP and 136 patients with SAP were randomized into control, high-dose octreotide (High-O) and low-dose octreotide (Low-O) groups. In addition to the conventional managements administrated in control group, High-O group received an intravenous infusion of octreotide at 50 μg/h × 3d + 25 μg/h × 4d, and Low-O group received octreotide at 25 μg/h × 7d. The major primary outcomes included the numbers of predicted SAP patients which developed SAP after intervention and the number of patients with SAP amelioration. Secondary outcomes included APACHE II, SIRS scores, plasma levels of somatostatin (SST), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6). There were no significant differences between the control and Low-O groups in terms of prevention and treatment for SAP. The incidence of SAP in patients with predicted SAP who received High-O was significantly lower than the Low-O group: 37.5% vs. 59.8%, p=0.005. Compared with Low-O group, the number of SAP patients in the SAP arm in the High-O group was reduced by 29.8%. Plasma levels of SST in both predicted SAP and the SAP patients were efficiently recovered (from 132.71±31.40 pg/ml to 180.00±23.50 pg/ml, p<0.05) after high-dose octreotide supplementation, which concomitantly reduced TNF-α and IL-6 levels. High-dose octreotide administration within 48h after AP onset may efficiently reduce the risk of SAP developing and partly attenuate SAP through raising plasma SST to a normal level and decreasing IL-6 and TNF-α.

Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

OBJECTIVE

To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

The clinical course of acute pancreatitis and the inflammatory mediators that drive it

Acute pancreatitis (AP) is a common emergency condition. In the majority of cases, it presents in a mild and self-limited form. However, about 20% of patients develop severe disease with local pancreatic complications (including necrosis, abscess, or pseudocysts), systemic organ dysfunction, or both. A modern classification of AP severity has recently been proposed based on the factors that are causally associated with severity of AP. These factors are both local (peripancreatic necrosis) and systemic (organ failure). In AP, inflammation is initiated by intracellular activation of pancreatic proenzymes and/or nuclear factor-κB. Activated leukocytes infiltrate into and around the pancreas and play a central role in determining AP severity. Inflammatory reaction is first local, but may amplify leading to systemic overwhelming production of inflammatory mediators and early organ failure. Concomitantly, anti-inflammatory cytokines and specific cytokine inhibitors are produced. This anti-inflammatory reaction may overcompensate and inhibit the immune response, rendering the host at risk for systemic infection. Currently, there is no specific treatment for AP. However, there are several early supportive treatments and interventions which are beneficial. Also, increasing the understanding of the pathogenesis of systemic inflammation and the development of organ dysfunction may provide us with future treatment modalities.

Use of plasmapheresis in managing the diagnostic dilemma of symptomatic hypertriglyceridemia

We present a case study of a 29-year-old male who presented with abdominal pain typical for pancreatitis. Detailed history and investigations revealed that the cause of abdominal pain was secondary to the raised triglyceride levels. It was difficult to distinguish whether he had hypertriglyceridemia-induced abdominal pain or acute pancreatitis, given that he had only a mildly raised lipase and a normal contrast computed tomography scan of the pancreas. The abdominal pain resolved with the fall in the triglyceride levels following plasmapheresis. Plasmapheresis is an underevaluated modality of the treatment of hypertriglyceridemia due to its cost and availability.

Prevention of severe acute pancreatitis with octreotide in obese patients: a prospective multi-center randomized controlled trial

OBJECTIVES

To evaluate the efficacy of octreotide in preventing severe acute pancreatitis (SAP) in obese patients.

METHODS

A prospective multi-center partly randomized control trial was conducted in patients with mild acute pancreatitis (AP). Nonobese patients received conventional management (nonobese-C, n = 82), whereas obese patients (body mass index ≥ 25 kg/m(2)) were randomized into 2 groups: obese-C (n = 79), who received conventional management, and obese-C+O (n = 82), who received conventional management plus intravenous infusion of octreotide, 50 μg/h for 72 hours.

RESULTS

The risk ratio and relative risk reduction in the development of SAP in the obese-C+O group were 0.27 (95% confidence interval, 0.10-0.69) and 0.73 (95% confidence interval, 0.31-0.90), respectively. The number of cases developing local complications in the obese-C+O group was significantly smaller than that in the obese-C group: 4.9% vs 19%, P = 0.006. The plasma level of somatostatin in the obese-C+O group was significantly higher than that in the obese-C group: 165.5 ± 42.6 vs 112.1 ± 24.86 pg/mL, P < 0.05. Supplement of octreotide also accompanied with reduction in plasma levels of tumor necrosis factor α and IL-6.

CONCLUSIONS

Intravenous administration of octreotide (50 μg/h) for 72 hours in the early stage of AP could prevent the development of SAP effectively in obese patients by raising plasma somatostatin to a normal level and reducing circulating cytokines.

Resultados do tratamento da pancreatite aguda grave

OBJETIVO: Avaliar os resultados do Protocolo de Atendimento de pacientes com diagnóstico de pancreatite aguda grave. MÉTODOS: Foram analisados, consecutivamente, a partir de janeiro de 2002, idade, sexo, etiologia, tempo de internação, tipo de tratamento e mortalidade de 37 pacientes portadores de pancreatite aguda grave. RESULTADOS: A idade dos pacientes variou de 20 a 88 anos (média de 50 anos); 27% foram do sexo feminino e 73% do masculino. O tempo médio global de internação foi 47 dias. Treze pacientes foram tratados cirurgicamente; a média de operações realizadas foi duas por paciente. Ocorreram seis óbitos dentre os pacientes submetidos ao tratamento cirúrgico (46%) e dois óbitos no grupo submetido somente ao tratamento clínico (8,3%). A mortalidade global foi 21% CONCLUSÃO: Após a modificação na forma de abordagem dos pacientes com pancreatite aguda grave, houve diminuição da mortalidade e uma tendência para a conduta expectante.

CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety

OBJECTIVE

The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis.

MATERIALS AND METHODS

From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates.

RESULTS

Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed.

CONCLUSION

Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.

Taurine attenuates liver injury by downregulating phosphorylated p38 MAPK of Kupffer cells in rats with severe acute pancreatitis

This study was undertaken to clarify the effects of taurine on liver injury in rats with severe acute pancreatitis (SAP). Rats were randomly assigned to three groups: a sham operation (SO), a SAP (established by infusion of 5% taurocholate), and a SAP given taurine (Taur). At 12 and 24 h post-operation, taurine pretreatment significantly attenuated hepatic tissue injury induced by SAP, and concurrently, serum alanine aminotransferase, aspartate transaminase, and amylase levels were significantly reduced by taurine pretreatment. Compared with the SO group, the total and phosphorylated p38 mitogen-activated protein kinase (p38 MAPK) expression and nuclear factor-κB (NF-κB) activity of Kupffer cells (KCs) were significantly higher in the SAP group, but taurine pretreatment inhibited the total and phosphorylated p38 MAPK expression and NF-κB activity of KCs in the SAP group. The increase of tumor necrosis factor-α and interleukin-lβ in cultured supernate of the SAP rat-derived KCs was also significantly inhibited by taurine pretreatment. These results suggest that taurine pretreatment ameliorated liver injury in rats with SAP mainly by inhibiting phosphorylated p38 MAPK and NF-κB activity in KCs, which may play an important role in liver injury.

The classification of acute pancreatitis: Current status

The Atlanta Classification of acute pancreatitis (AP) is widely accepted and has been used by physicians and radiologists since 1992. However, advances in knowledge of the disease process, improved imaging, and ever-changing treatment options have rendered some of its definitions ambiguous and highlighted the inadequacy of its classification of severity. This review discusses revision of the Atlanta Classification (2008) and it describes a new determinant-based classification (2012). In contrast to the Atlanta Classification, the revised version and new classification are based on evidence but still need to be developed through systematic review of new data and further international consultation.