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Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14:27. [PMID: 31210778 PMCID: PMC6567462 DOI: 10.1186/s13017-019-0247-0] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Medicine, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Chad G. Ball
- Foothills Medical Centre & the University of Calgary, Calgary, AB Canada
| | - Neil Parry
- London Health Sciences Centre, London, ON Canada
| | | | - Daan Wolbrink
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Predictive value of serum cyclophilin A concentrations after acute pancreatitis. Clin Chim Acta 2018; 484:237-245. [PMID: 29883632 DOI: 10.1016/j.cca.2018.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cyclophilin A is identified as a biomarker for inflammation. We elucidated prognostic significance of serum cyclophilin A (CypA) concentrations in acute pancreatitis (AP). METHODS In this prospective and observational study, serum CypA concentrations were quantified in 210 AP patients and 100 healthy controls. We recorded local complication, in-hospital mortality and organ failure. Disease severity was assessed using the traditional predictors, namely Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score and sequential organ failure assessment score. RESULTS Serum CypA concentrations were significantly lower in controls than in AP group. CypA concentrations after AP were highly correlated with the traditional predictors and other inflammatory mediators, including blood erythrocyte sedimentation rate, procalcitonin levels, white blood cell count and C-reactive protein levels. Serum CypA emerged as an independent predictor for in-hospital local complication, organ failure and mortality. Under receiver operating characteristic curve, serum CypA possessed similar prognostic ability, as compared to the traditional predictors. Its predictive ability was almost similar to that of procalcitonin levels and significantly exceeded those of the other inflammatory mediators. Also, it significantly improved prognostic performance of the traditional predictors. CONCLUSIONS Increased serum CypA concentrations have close relation to the severity, inflammation and prognosis, substantializing CypA as a potential prognostic biomarker of AP.
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Hagjer S, Kumar N. Evaluation of the BISAP scoring system in prognostication of acute pancreatitis - A prospective observational study. Int J Surg 2018; 54:76-81. [PMID: 29684670 DOI: 10.1016/j.ijsu.2018.04.026] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/05/2018] [Accepted: 04/14/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Severe acute pancreatitis has a high mortality and its early identification is important for management and risk stratification. The bedside index for severity in acute pancreatitis (BISAP) is a simple scoring system done at admission which predicts the severity of pancreatitis. Procalcitonin is an inflammatory marker which is raised very early and helps in early prediction of the severity of disease. This study aims to evaluate the BISAP score and Procalcitonin in prognostication of acute pancreatitis. METHODS A prospective observational study of 60 patients presenting with acute pancreatitis was done at XXX Medical College and Hospital from July 2015 to June 2016. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. Procalcitonin card test was done for all patients. The patients were stratified according by BISAP score and procalcitonin positivity into categories of severe pancreatitis, organ failure and pancreatic necrosis, as well as the number of deaths. The comparison of BISAP with other scoring systems, Procalcitonin (PCT), C-reactive protein (CRP), hematocrit, and body mass index (BMI) was done by the area under the receiver-operating curve (AUC) to prediction of severe acute pancreatitis, organ failure, necrosis, and death. RESULTS Of the 60 patients, 14 (23.3%) developed severe acute pancreatitis, 11 (18.3%) Organ failure, 21 (35%) pancreatic necrosis and 7 (11.6%) died. A BISAP score of ≥3 was a statistically significant cutoff value. AUCs for predicting severe pancreatitis and death of BISAP were 0.875 and 0.740respectively, similar to those for Ranson criteria (0.802, 0.763) and APACHE-II (0.891, 0.769) and greater than AUCs for CTSI (0.641, 0.554). The AUC for prediction of organ failure were 0.906, 0.833, 0.874 and 0.623 for BISAP, Ranson criteria, APACHE-II, and CTSI respectively. AUCs for PCT predicting severity, organ failure, and death were 0.940, 0.923 and 0.769 respectively were similar to BISAP but greater than those for CRP (0.755, 0.719, 0.693), hematocrit (0.540, 0.570, 0.550), and BMI (0.493, 0.523, 0.497). CONCLUSION The BISAP predicts severity, organ failure and death, in acute pancreatitis very well.It is as good as APACHE-II but better than Ranson criteria, CTSI, CRP, hematocrit, and BMI. PCT is a promising inflammatory marker with prediction rates similar to BISAP.
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Affiliation(s)
- Sumitra Hagjer
- Department of General Surgery, Silchar Medical College & Hospital, Silchar, Assam, India
| | - Nitesh Kumar
- Department of General Surgery, Silchar Medical College & Hospital, Silchar, Assam, India.
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Risk Factors for the Need of Surgical Necrosectomy After Percutaneous Catheter Drainage in the Management of Infection Secondary to Necrotizing Pancreatitis. Pancreas 2018. [PMID: 29517639 DOI: 10.1097/mpa.0000000000001031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study aimed to assess the need of surgical necrosectomy after percutaneous catheter drainage (PCD) for infected necrotizing pancreatitis. METHODS The clinical data of documented/suspected patients who were treated with a step-up approach were extracted and analyzed. RESULTS Of the 329 patients enrolled, the initial PCD was performed at 12 (interquartile range, 9-15) days since onset and 35.3% were cured by PCD alone. In the pre-PCD model, mean computed tomographic (CT) density of necrotic fluid collection (NFC; P < 0.001), and multiple-organ failure (MOF; P < 0.001) within 24 hours before the initial PCD were independent risk factors, and a combination of the previously mentioned 2 factors produced an area under the curve of 0.775. In the post-PCD model, mean CT density of NFC (P = 0.041), MOF (P = 0.002), and serum procalcitonin level (P = 0.035) 3 days after the initial PCD were independent risk factors, and a combination of these previously mentioned factors produced an area under the curve of 0.642. CONCLUSIONS Both mean CT density of NFC and MOF are independent pre- and post-PCD risk factors for the need of necrosectomy after PCD. Post-PCD serum procalcitonin level might be a respondent factor that is correlated with the necessity of necrosectomy.
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Simsek O, Kocael A, Kocael P, Orhan A, Cengiz M, Balcı H, Ulualp K, Uzun H. Inflammatory mediators in the diagnosis and treatment of acute pancreatitis: pentraxin-3, procalcitonin and myeloperoxidase. Arch Med Sci 2018; 14:288-296. [PMID: 29593801 PMCID: PMC5868652 DOI: 10.5114/aoms.2016.57886] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/07/2015] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is the third most common gastrointestinal disease at hospital admission. The etiology and pathogenesis of this disease are not completely clear. Our study was intended to determine the systemic levels of pentraxin-3 (PTX-3), myeloperoxidase (MPO), procalcitonin (PCT), and C-reactive protein (CRP) as prognostic parameters in early stages of AP. We also determined the effects of treatment on PTX-3, MPO, PCT and CRP levels in AP. MATERIAL AND METHODS The study group comprised 44 AP patients (22 male, 22 female; age: 49.3 ±16.9 years) referred to our outpatient clinic. Additionally, our investigation included a control group of 30 healthy volunteers (18 male, 12 female; age: 50.8 ±12.6 years). RESULTS Leukocytes, glucose, aspartate aminotransferase (AST (SGOT)), alanine aminotransferase (ALT (SGPT)), alkaline phosphatase (ALP), total and direct bilirubin levels were significantly higher in the AP group (p < 0.05, all). CRP, PTX-3, MPO and PCT were considerably higher in the AP group (p < 0.001, all), and after treatment, CRP, PTX-3, MPO and PCT levels were significantly lower (p < 0.001, all). CONCLUSIONS Our findings indicated that the CRP, PTX-3, MPO and PCT levels increase in patients with AP and hence these indicators can be used as diagnostic factors to predict inflammation severity in AP. It was revealed that after treatment, there were significant reductions in biomarker levels. However, further research is needed in order to understand how these biomarkers can help to monitor inflammatory responses in AP.
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Affiliation(s)
- Osman Simsek
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ahmet Kocael
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pınar Kocael
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Anıl Orhan
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mahir Cengiz
- Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Huriye Balcı
- Central Research Laboratory, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Kenan Ulualp
- Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hafize Uzun
- Department of Biochemistry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Cortisol Outperforms Novel Cardiovascular, Inflammatory, and Neurohumoral Biomarkers in the Prediction of Outcome in Acute Pancreatitis. Pancreas 2018; 47:55-64. [PMID: 29215538 DOI: 10.1097/mpa.0000000000000962] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The aims of this study were to assess whether copeptin, pro-atrial natriuretic peptide, proadrenomedullin, and cortisol are associated with disease severity in patients with acute pancreatitis (AP) and to compare their ability in predicting organ failure or death. METHODS From April 2011 to January 2015, 142 patients with AP were included in this prospective single-center study and observed for 4 days. Disease severity was rated by the Atlanta 1992 and 2012 criteria and organ failure by the modified Marshall score. The aforementioned laboratory markers, C-reactive protein, and procalcitonin were measured. RESULTS Patients with moderate to severe AP showed significantly higher plasma concentrations of all biomarkers than did those with mild AP. Overall, 30 organ failures or deaths occurred. All biomarkers except cortisol had only modest discriminatory ability, with areas under the receiver operating characteristic curve (AUCs) between 0.44 and 0.66. Cortisol showed an AUC of 0.78 compared with the Acute Physiology and Chronic Health Evaluation II score with an AUC of 0.75. CONCLUSIONS Cortisol was the best predictor of organ failure or death. All biomarkers were associated with disease severity to a similar degree as C-reactive protein, the criterion-standard marker in AP. Further studies are warranted to define their clinical role.
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Sharma D, Jakkampudi A, Reddy R, Reddy PB, Patil A, Murthy HVV, Rao GV, Reddy DN, Talukdar R. Association of Systemic Inflammatory and Anti-inflammatory Responses with Adverse Outcomes in Acute Pancreatitis: Preliminary Results of an Ongoing Study. Dig Dis Sci 2017; 62:3468-3478. [PMID: 29080144 DOI: 10.1007/s10620-017-4813-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 10/16/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This paper reports preliminary data of an ongoing study that evaluates the association of systemic inflammatory response (SIRS) with early severe acute pancreatitis (ESAP) and compensatory anti-inflammatory response syndrome (characterized by HLA-DR down-regulation) with infected pancreatic necrosis (IPN). METHODS Consecutive patients presenting within 72 h of symptom onset with organ dysfunction and/or local complications were included. Following parameters were recorded: demographics, etiology, SIRS, APACHE II, creatinine, BUN. Circulating IL-8, IL-6, IL-10, TNF-alpha concentrations and expression of HLA-DR and IL-10 by qRT-PCR in PBMCs were measured. Strength of associations of cytokine concentration and HLA-DR/IL-10 expression with outcomes was expressed as Hedges' G and relative risk (95% CI). RESULTS Twenty-eight patients (10 MSAP; 18 SAP) fulfilled inclusion criteria. Twelve patients had ESAP and eight presented with organ failure. Admission SIRS worsened in eight (28.6%) patients over 48 h. Sixteen (57.1%) patients developed primary IPN. Twenty-one (75%) patients had HLA-DR down-regulation during the first week, which persisted to the second week in 12 (42.9%) patients. IL-8, IL-6, and TNF-α progressively increased from healthy controls to MAP to MSAP to SAP. IL-6 and TNF-α was higher in the patients who developed ESAP (p = 0.01 and 0.05, respectively). Patients who died within the first week also had a significantly elevated concentration of IL-6 and TNF-α (p = 0.02 and 0.01, respectively). The relative risk (95% CI) of developing primary IPN with persistent HLA-DR down-regulation till the second week of illness was 11.3 (1.6-82.4; p = 0.01). CONCLUSIONS Our study objectively demonstrates significant association of ESAP and early mortality with primary cytokine response, and development of IPN with persistent HLA-DR down-regulation.
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Affiliation(s)
- Deepesh Sharma
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, Telangana, 500082, India
| | - Aparna Jakkampudi
- Division of Basic and Translational Sciences, Asian Healthcare Foundation, Hyderabad, India
- Wellcome DBT India Alliance Laboratories, Asian Healthcare Foundation, Hyderabad, India
| | - Ratnakar Reddy
- Division of Basic and Translational Sciences, Asian Healthcare Foundation, Hyderabad, India
| | | | - Aasish Patil
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, Telangana, 500082, India
| | - H V V Murthy
- Department of Biostatistics, Asian Institute of Gastroenterology, Hyderabad, India
| | - G Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, Telangana, 500082, India
| | - Rupjyoti Talukdar
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad, Telangana, 500082, India.
- Division of Basic and Translational Sciences, Asian Healthcare Foundation, Hyderabad, India.
- Wellcome DBT India Alliance Laboratories, Asian Healthcare Foundation, Hyderabad, India.
- Pancreas Research Group, Asian Healthcare Foundation, 6-3-661 Somajiguda, Hyderabad, Telangana, 500082, India.
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Majidi S, Golembioski A, Wilson SL, Thompson EC. Acute Pancreatitis: Etiology, Pathology, Diagnosis, and Treatment. South Med J 2017; 110:727-732. [PMID: 29100225 DOI: 10.14423/smj.0000000000000727] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute pancreatitis is a fascinating disease. In the United States, the two most common etiologies of acute pancreatitis are gallstones and excessive alcohol consumption. The diagnosis of acute pancreatitis is made with a combination of history, physical examination, computed tomography scan, and laboratory evaluation. Differentiating patients who will have a benign course of their pancreatitis from patients who will have severe pancreatitis is challenging to the clinician. C-reactive protein, pro-calcitonin, and the Bedside Index for Severity of Acute Pancreatitis appeared to be the best tools for the early and accurate diagnosis of severe pancreatitis. Early laparoscopic cholecystectomy is indicated for patients with mild gallstone pancreatitis. For patients who are going to have a prolonged hospitalization, enteral nutrition is preferred. Total parenteral nutrition should be reserved for patients who cannot tolerate enteral nutrition. Prophylactic antibiotics are not indicated for patients with pancreatic necrosis. Surgical intervention for infected pancreatic necrosis should be delayed as long as possible to improve patient outcomes.
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Affiliation(s)
- Shirin Majidi
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Adam Golembioski
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Stephen L Wilson
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Errington C Thompson
- From the Joan Edwards School of Medicine, Marshall University, Huntington, West Virginia
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He WH, Zhu Y, Zhu Y, Jin Q, Xu HR, Xion ZJ, Yu M, Xia L, Liu P, Lu NH. Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis. J Gastroenterol Hepatol 2017; 32:1895-1901. [PMID: 28419583 DOI: 10.1111/jgh.13803] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/19/2017] [Accepted: 04/02/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND The purpose of this study was to clarify whether the current scoring systems and single serum markers used in pancreatitis remain applicable for the early prediction of infected pancreatic necrosis (IPN) and the severity and mortality of acute pancreatitis (AP) in accordance with the revised Atlanta and determinant-based classifications. METHODS Demographic, clinical, and laboratory data from 708 consecutive patients with AP were prospectively collected between January 2011 and December 2012. The severity was classified using the revised Atlanta and determinant-based classification systems. The predictive accuracies for moderately severe AP (MSAP), severe AP (SAP), critically severe AP (CAP), IPN, and mortality were measured using area under the receiver operating characteristic curves. RESULTS The receiver operating characteristic analysis showed that the multifactor scoring systems and single serum markers had a low predictive accuracy regarding moderately severe AP. The Acute Physiology and Chronic Health Evaluation (APACHE) II score had the highest accuracy in predicting SAP with area under the curve (AUC) values of 0.75 (95% CI = 0.71-0.79) and 0.77 (95% CI = 0.73-0.81) at 24 and 48 h after admission, respectively. Procalcitonin was the most accurate predictor for CAP and IPN, with respective AUCs of 0.86 (95% CI = 0.82-0.89) and 0.83 (95% CI = 0.78-0.87) at 48 h after admission. In predicting mortality, both the APACHE II score and blood urea nitrogen had the highest accuracy. CONCLUSIONS The APACHE II score had the highest predictive accuracy for SAP and mortality as defined by the revised Atlanta classification, whereas procalcitonin was the most accurate predictor for CAP and IPN.
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Affiliation(s)
- Wen-Hua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qi Jin
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Hong-Rong Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhi-Juan Xion
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Min Yu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Nong-Hua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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How good is procalcitonin as a marker in case of sepsis in diabetes mellitus? Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Chen HZ, Ji L, Li L, Wang G, Bai XW, Cheng CD, Sun B. Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis. Medicine (Baltimore) 2017; 96:e7487. [PMID: 28746189 PMCID: PMC5627815 DOI: 10.1097/md.0000000000007487] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
To assess the association between the clinical parameters within 48 hours of admission and the occurrence of infected pancreatic necrosis (IPN) during the late phase of necrotizing pancreatitis (NP).All patients were divided into 2 groups, the IPN and non-IPN groups. The clinical data were retrospectively analyzed. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between clinical parameters and IPN secondary to NP. The performance of each independent variable was plotted by the receiver-operating characteristic (ROC) curve. Consequently, the cut-off level of each independent variable with its sensitivity and specificity was calculated.A total of 215 patients were enrolled in our study. Among them, 87 (40.5%) patients developed IPNs after a median of 13.5 (9.5-23.0) days from admission. Multivariate analysis indicated that the level of hematocrit (HCT) from 40% to 50% (P=.012, odds ratio (OR) = 2.407), HCT over 50% (P < .009, OR = 6.794), blood urea nitrogen (BUN) (P = .040, OR = 1.894), C-reactive protein (CRP) (P = .043, OR = 1.837), and procalcitonin (PCT) (P = .002, OR = 2.559) were independent risk factors of IPN secondary to NP. The ROC cures revealed that the area under the ROC (AUC) of the maximum level of HCT, BUN, CRP, and PCT within 48 hours of admission was 0.687, 0.620, 0.630, and 0.674 respectively. Furthermore, the combination of these 4 individual parameters contributes to a more preferable AUC of 0.789 with a sensitivity of 67.8% and specificity of 77.3%.The maximum levels of PCT, CRP, HCT, and BUN within 48 hours of admission are independent factors of IPN and their combination might accurately predict the occurrence of IPN secondary to NP.
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Chen H, Wang W, Hong Y, Zhang H, Hong C, Liu X. Single-blinded, randomized, and controlled clinical trial evaluating the effects of Omega-3 fatty acids among septic patients with intestinal dysfunction: A pilot study. Exp Ther Med 2017; 14:1505-1511. [PMID: 28810616 PMCID: PMC5525580 DOI: 10.3892/etm.2017.4680] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/20/2017] [Indexed: 11/25/2022] Open
Abstract
Sepsis is a systemic inflammatory reaction, which is aggravated by aspects of the immune response that are thought to be inhibited by Omega-3 fatty acids. The aim of the present study was to determine if Omega-3 fatty acid could modulate immunological function and improve survival rate among septic patients with intestinal dysfunction. A total of 48 mechanically ventilated patients with intestinal dysfunction were included in this prospective, randomized and single-blind clinical study. Patients were randomly divided into control (group A) and treatment groups (group B). The treatment protocol for all the participants followed the Sepsis Survival Campaign guidelines, and group B received total parenteral nutrition containing 100 ml of Omega-3 fatty acids (containing 10 g refined fish oil) per day in addition to the standard treatment applied in group A. Group B had a significantly lower mortality rate compared with group A (12.5 vs. 41.7%, P<0.05) during the 28-day follow-up. Group B also had lower Acute Physiology and Chronic Health Evaluation II scores (P<0.05) and lower Marshall scores (P<0.05) at day 7. In addition, group B had a higher ratio of T helper to inducer lymphocytes as well as a higher ratio of CD4 to CD8 lymphocytes (P<0.01 for both) than group A. It was concluded that Omega-3 fatty acids improved T helper/inducer and CD4/CD8 ratios, and may have reduced mortality, among septic patients with intestinal dysfunction.
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Affiliation(s)
- Huaisheng Chen
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Wei Wang
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Yingcai Hong
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Huadong Zhang
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Chengying Hong
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Xueyan Liu
- Intensive Care Unit, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
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Gong JD, Qi XF, Zhang Y, Li HL. Increased admission serum cold-inducible RNA-binding protein concentration is associated with prognosis of severe acute pancreatitis. Clin Chim Acta 2017; 471:135-142. [PMID: 28587954 DOI: 10.1016/j.cca.2017.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 05/19/2017] [Accepted: 06/02/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cold-inducible RNA-binding protein (CIRP) is a pro-inflammatory cytokine. This study assessed its relation to disease severity and major adverse events (namely local complications, organ failure and in-hospital mortality) of severe acute pancreatitis (SAP) and its discriminatory ability for SAP. METHODS This prospective and observational study recruited a total of 102 SAP patients, 48 patients with mild acute pancreatitis and 102 healthy individuals. Serum CIRP concentrations were determined using enzyme-linked immunosorbent assay. RESULTS Serum CIRP concentrations were significantly higher in patients compared to controls. Serum CIRP concentrations were highly correlated with the circulating concentrations of common inflammatory mediators (i.e., procalcitonin, C-reactive protein and white blood cell) and the traditional predictors of disease severity (namely Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score and sequential organ failure assessment score). CIRP in serum was an independent predictor for major adverse events. Serum CIRP concentrations showed high predictive value for major adverse events, and possessed high discriminatory performance for SAP. Moreover, its effects significantly exceeded those of the preceding inflammatory mediators. CONCLUSIONS Increased serum CIRP concentrations clearly reflect SAP severity and prognosis and significantly distinguish SAP, substantializing CIRP as a potential SAP biomarker.
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Affiliation(s)
- Jian-De Gong
- Department of Gastroenterology, The Yinzhou People's Hospital, 251 Baizhang East Road, Ningbo 315040, China
| | - Xu-Fei Qi
- Department of Gastroenterology, The Yinzhou People's Hospital, 251 Baizhang East Road, Ningbo 315040, China
| | - Yi Zhang
- Department of Gastroenterology, The Yinzhou People's Hospital, 251 Baizhang East Road, Ningbo 315040, China
| | - Hong-Liang Li
- Department of Gastroenterology, The Yinzhou People's Hospital, 251 Baizhang East Road, Ningbo 315040, China.
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Sternby H, Hartman H, Johansen D, Thorlacius H, Regnér S. IL-6 and CRP are superior in early differentiation between mild and non-mild acute pancreatitis. Pancreatology 2017; 17:550-554. [PMID: 28610827 DOI: 10.1016/j.pan.2017.05.392] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/03/2017] [Accepted: 05/29/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Hanna Sternby
- Department of Surgery, Institution of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Sweden
| | - Hannes Hartman
- Department of Gastroenterology, Institution of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Sweden
| | - Dorthe Johansen
- Department of Surgery, Institution of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Sweden
| | - Henrik Thorlacius
- Department of Surgery, Institution of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Sweden
| | - Sara Regnér
- Department of Surgery, Institution of Clinical Sciences, Malmö, Skåne University Hospital, Lund University, Sweden.
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Roggenbuck D, Goihl A, Hanack K, Holzlöhner P, Hentschel C, Veiczi M, Schierack P, Reinhold D, Schulz HU. Serological diagnosis and prognosis of severe acute pancreatitis by analysis of serum glycoprotein 2. Clin Chem Lab Med 2017; 55:854-864. [PMID: 27837595 DOI: 10.1515/cclm-2016-0797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Glycoprotein 2 (GP2), the pancreatic major zymogen granule membrane glycoprotein, was reported to be elevated in acute pancreatitis in animal models. METHODS Enzyme-linked immunosorbent assays (ELISAs) were developed to evaluate human glycoprotein 2 isoform alpha (GP2a) and total GP2 (GP2t) as specific markers for acute pancreatitis in sera of 153 patients with acute pancreatitis, 26 with chronic pancreatitis, 125 with pancreatic neoplasms, 324 with non-pancreatic neoplasms, 109 patients with liver/biliary disease, 67 with gastrointestinal disease, and 101 healthy subjects. GP2a and GP2t levels were correlated with procalcitonin and C-reactive protein in 152 and 146 follow-up samples of acute pancreatitis patients, respectively. RESULTS The GP2a ELISA revealed a significantly higher assay accuracy in contrast to the GP2t assay (sensitivity ≤3 disease days: 91.7%, specificity: 96.7%, positive likelihood ratio [LR+]: 24.6, LR-: 0.09). GP2a and GP2t levels as well as prevalences were significantly elevated in early acute pancreatitis (≤3 disease days) compared to all control cohorts (p<0.05, respectively). GP2a and GP2t levels were significantly higher in patients with severe acute pancreatitis at admission compared with mild cases (p<0.05, respectively). Odds ratio for GP2a regarding mild vs. severe acute pancreatitis with lethal outcome was 7.8 on admission (p=0.0222). GP2a and GP2t levels were significantly correlated with procalcitonin [Spearman's rank coefficient of correlation (ρ)=0.21, 0.26; p=0.0110, 0.0012; respectively] and C-reactive protein (ρ=0.37, 0.40; p<0.0001; respectively). CONCLUSIONS Serum GP2a is a specific marker of acute pancreatitis and analysis of GP2a can aid in the differential diagnosis of acute upper abdominal pain and prognosis of severe acute pancreatitis.
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Affiliation(s)
- Dirk Roggenbuck
- Institute of Biotechnology, Faculty of Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg
| | - Alexander Goihl
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke University, Magdeburg
| | - Katja Hanack
- Chair of Immunotechnology, Department of Biochemistry and Biology, University of Potsdam, Potsdam
| | - Pamela Holzlöhner
- Chair of Immunotechnology, Department of Biochemistry and Biology, University of Potsdam, Potsdam
| | | | | | - Peter Schierack
- Institute of Biotechnology, Faculty of Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg
| | - Dirk Reinhold
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke University, Magdeburg
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Qi X, Yang F, Huang H, Du Y, Chen Y, Wang M, Zhu D, Yue X, Wang L. A reduced lymphocyte ratio as an early marker for predicting acute pancreatitis. Sci Rep 2017; 7:44087. [PMID: 28266603 PMCID: PMC5339824 DOI: 10.1038/srep44087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/01/2017] [Indexed: 01/21/2023] Open
Abstract
The early diagnosis and severity grading for acute pancreatitis (AP) are difficult to determine because of the complexity and differences in disease process. To date, few studies have investigated the role of lymphocyte ratio (LR) in AP. Therefore, the objective of the present study was to investigate the prognostic value of LR as an indicator in AP, as well as determine an optimal cut-off value for the severity prediction. There were two hundred four patients involved in this study, ninety-two of whom had severe acute pancreatitis (SAP). The LR was analyzed on admission and correlated with severity, which was determined using the Atlanta classification. The optimal cut-off value for LR was generated using receiving operator characteristic (ROC) curves. The results showed that the LR in the SAP group decreased significantly compared to the mild acute pancreatitis (MAP) group (8.82 vs. 13.43). The optimal cut-off value obtained from ROC curves was 0.081, with a sensitivity of 80.4%, a specificity of 53.3%, a positive likelihood ratio of 1.722, and a negative likelihood ratio of 0.368. In conclusion, the LR is obviously related to the condition of AP patients and is valuable for the differential diagnosis of SAP in early stages of AP.
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Affiliation(s)
- Xiuzhong Qi
- Department of Traditional Chinese Medicine, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China.,Department of Traditional Chinese Medicine, The Qingdao First Sanitarium of Navy, No. 27 Xianggang West Road, Qingdao 266071, China
| | - Fangyong Yang
- Department of Traditional Chinese Medicine, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
| | - Haitao Huang
- Laixi People’s Hospital, No. 69 Yantai Road, Laixi, 266600, China
| | - Yiqi Du
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
| | - Meitang Wang
- Department of emergency, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
| | - Dezeng Zhu
- Department of Traditional Chinese Medicine, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
| | - Xiaoqiang Yue
- Department of Traditional Chinese Medicine, Changzheng Hospital, Second Military Medical University, No. 415 Fengyang Road, Shanghai 200003, China
| | - Lina Wang
- Department of Traditional Chinese Medicine, Changhai Hospital, Second Military Medical University, No. 168 Changhai Road, Shanghai 200433, China
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Abstract
BACKGROUND Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines [all clinical questions (CQs) and recommendations are shown in supplementary information]. METHODS A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. RESULTS A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. CONCLUSIONS The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.
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Ileus is a predictor of local infection in patients with acute necrotizing pancreatitis. Pancreatology 2016; 16:966-972. [PMID: 27727097 DOI: 10.1016/j.pan.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/08/2016] [Accepted: 10/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & OBJECTIVES Infected pancreatic necrosis (IPN) is associated with increased morbidity and mortality. Gut barrier dysfunction has been shown to increase the risk of bacterial translocation from the gut into the pancreatic bed. The primary aim of the study is to evaluate if ileus, a clinical marker of gut barrier dysfunction, can predict the development of IPN. METHODS A retrospective cohort study of patients with necrotizing pancreatitis (NP) was conducted from 2000 to 2014. Ileus was defined as ≥2 of the following criteria: nausea/vomiting; inability to tolerate a diet, absence of flatus, abdominal distension and features of ileus on imaging. Extensive necrosis was defined as >30% nonenhancing pancreatic parenchyma on contrast-enhanced CT. Multivariable cox proportional hazard analysis was used to evaluate known and potential predictors of IPN. RESULTS 142 patients were identified with NP, 61 with IPN and 81 with sterile necrosis. In comparison to a diagnosis of ileus documented in the medical chart, the ileus criteria had a sensitivity, specificity and positive and negative predictive value of 100%, 93%, 78% and 100%, respectively. On multivariate cox proportional hazard analysis, ileus [HR:2.6; 95%CI:1.4-4.9] and extensive necrosis [HR:2.8; 95%CI:1.3-5.8] were independently associated with the development of IPN while there was no association with bacteremia [HR:1.09; 95%CI:0.6-2.1]. CONCLUSION Ileus in NP can be accurately defined using surgical criteria. Ileus is independently associated with the future development of IPN. Further studies will be needed to determine if ileus can serve as a clinical marker to direct therapeutic interventions aimed at reducing the incidence of IPN.
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Abstract
Jean-Louis Vincent outlines why combinations of biomarkers will be central to the future of sepsis diagnosis.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
- * E-mail:
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Mayumi T, Yoshida M, Tazuma S, Furukawa A, Nishii O, Shigematsu K, Azuhata T, Itakura A, Kamei S, Kondo H, Maeda S, Mihara H, Mizooka M, Nishidate T, Obara H, Sato N, Takayama Y, Tsujikawa T, Fujii T, Miyata T, Maruyama I, Honda H, Hirata K. The Practice Guidelines for Primary Care of Acute Abdomen 2015. J Gen Fam Med 2016. [DOI: 10.14442/jgfm.17.1_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Li HC, Fan XJ, Chen YF, Tu JM, Pan LY, Chen T, Yin PH, Peng W, Feng DX. Early prediction of intestinal mucosal barrier function impairment by elevated serum procalcitonin in rats with severe acute pancreatitis. Pancreatology 2016; 16:211-7. [PMID: 26804005 DOI: 10.1016/j.pan.2015.12.177] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 12/24/2015] [Accepted: 12/27/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate serum procalcitonin (PCT) levels as a prognostic indicator of intestinal barrier function impairment in rats with severe acute pancreatitis (SAP). METHODS Thirty-six male Sprague Dawley rats were randomly grouped into SAP group (injected sodium taurocholate via biliopancreatic duct), Gln group (gavaged with glutamine after modeling), and control group. Blood, pancreatic, and terminal ileum tissues were obtained from the rats after 6 h of modeling. Serum amylase (Amy) levels were determined using an automatic biochemical detector, while endotoxin (ET), diamine oxidase (DAO), and PCT levels were measured by ELISA test. The pathology of pancreatic and small intestine tissues were observed. PCT protein expression in intestinal tissues were detected by immunohistochemistry and western blot. RESULT Pancreatic and intestinal injuries in Gln group were significantly lower than SAP group. Serum amylase, DAO, and PCT levels in SAP and Gln groups differed greatly and were significantly higher than control group. Immuno-histochemistry and western blot results showed that PCT protein expression levels in small intestine tissues of SAP group were higher than Gln group and control group. Serum PCT levels had a significant correlation with serum endotoxin, DAO levels and intestinal mucosal injury scores. CONCLUSION PCT expression in serum and intestinal tissues in SAP rats increased significantly in the early stages of SAP, and was closely related to the onset and degree of intestinal barrier function impairment. Thus, our results showed that measuring serum PCT can be used to predict intestinal mucosal barrier function impairment in SAP rats.
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Affiliation(s)
- Hong-chang Li
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Xin-juan Fan
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Ya-feng Chen
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Jia-min Tu
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Li-yun Pan
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Teng Chen
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Pei-hao Yin
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Wen Peng
- Laboratory Center, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China
| | - Dian-xu Feng
- Department of General Surgery, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200062, China.
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Abstract
OBJECTIVES We aimed to compare the prognostic value of various predictors and complex scoring systems for prediction of severe acute pancreatitis (SAP) according to the revised Atlanta classification. METHODS C-reactive protein (CRP) and procalcitonin were obtained on admission, and CRP level 24 hours after admission (CRP2) was measured. Various scoring systems including Ranson, Acute Physiology and Chronic Health Examination (APACHE II), the Bedside Index for Severity in Acute Pancreatitis, and Computed Tomography Severity Index (CTSI) were calculated. RESULTS There were 146 patients with acute pancreatitis (mean age, 50.6 ± 18.3 years; 63% male), of which 43 patients (29.5%) received a diagnosis of moderately severe AP, and 17 patients (11.6%) received a diagnosis of SAP. In patients with moderately severe acute pancreatitis to SAP, CTSI (odds ratio [OR], 10.46; 95% confidence interval [CI], 4.3-25.43; P < 0.001), APACHE II (OR, 3.87; 95% CI, 1.18-12.64; P = 0.025), and CRP2 (OR, 4.5; 95% CI, 1.53-13.1; P = 0.006) were strongly related to moderately severe acute pancreatitis and SAP. In patients with SAP compared with mild to moderately severe AP, procalcitonin (OR, 4.36; 95% CI, 1.01-18.96; P = 0.049) was the only factor strongly associated with SAP. CONCLUSIONS Procalcitonin was the best predictor for patients with SAP; CTSI, APACHE II, and CRP2 were valuable predictors for patients with moderately severe acute pancreatitis and SAP.
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73
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Mayumi T, Yoshida M, Tazuma S, Furukawa A, Nishii O, Shigematsu K, Azuhata T, Itakura A, Kamei S, Kondo H, Maeda S, Mihara H, Mizooka M, Nishidate T, Obara H, Sato N, Takayama Y, Tsujikawa T, Fujii T, Miyata T, Maruyama I, Honda H, Hirata K. Practice Guidelines for Primary Care of Acute Abdomen 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 23:3-36. [PMID: 26692573 DOI: 10.1002/jhbp.303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.
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Affiliation(s)
- Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Akira Furukawa
- Department of Radiological Sciences, Faculty of Health Sciences and Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Osamu Nishii
- Department of Obstetrics and Gynecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, Kanagawa, Japan
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University, School of Medicine, Tokyo, Japan
| | - Seiji Kamei
- Department of Radiology, The Aichi Prefectural Federation of Agricultural Cooperatives for Health and Welfare Kainan Hospital, Aichi, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Shigenobu Maeda
- Emergency Department, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Mihara
- Center for Medical Education, University of Toyama, Toyama, Japan
| | - Masafumi Mizooka
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshihiko Nishidate
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norio Sato
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tomoyuki Tsujikawa
- Comprehensive Internal Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Tomoyuki Fujii
- Chairperson of the Executive Board, Japan Society of Obstetrics and Gynecology, Tokyo, Japan
| | - Tetsuro Miyata
- President, Japanese Society for Vascular Surgery, Tokyo, Japan
| | | | | | - Koichi Hirata
- President, Japanese Society for Abdominal Emergency Medicine, Tokyo, Japan
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Bréchot N, Hékimian G, Chastre J, Luyt CE. Procalcitonin to guide antibiotic therapy in the ICU. Int J Antimicrob Agents 2015; 46 Suppl 1:S19-24. [DOI: 10.1016/j.ijantimicag.2015.10.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Xu YH, Yan L, Bian C, Tian ZB, Jing X. Value of procalcitonin in assessing severity of acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2015; 23:4898-4904. [DOI: 10.11569/wcjd.v23.i30.4898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of procalcitonin (PCT) in assessing the severity of acute pancreatitis (AP).
METHODS: A total of 154 unrelated patients diagnosed with AP and 41 healthy control subjects were enrolled in this study. The 154 patients with AP were divided into three groups according to the severity of AP: mild acute pancreatitis (MAP) (n = 56), mild-severe acute pancreatitis (MSAP; n = 51), and severe acute pancreatitis (SAP; n = 47). Serological assays of PCT, C-reactive protein, hematocrit, and leukocytes were carried out in accordance with the standard clinical laboratory methods. The score of Bedside Index for Severity in Acute Pancreatitis (BISAP) was determined for all patients. Differences in the serum indexes between two groups, and the association between PCT and AP mortality were evaluated.
RESULTS: The levels of serum PCT were the highest in the SAP group, followed by the MSAP group, the MAP group, and the control group (P = 0.000). The levels of serum PCT were positively associated with BISAP score in patients with AP. The sensitivity and specificity of serum PCT in diagnosis of SAP, similar to those of the score of BISAP, were 77.8% and 87.1%, respectively. AP patients with a PCT level > 2.0 ng/mL had a poor prognosis.
CONCLUSION: Our results indicate that the levels of serum PCT may represent an early sensitive biomarker for evaluating the severity of AP.
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76
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McGurk P, Elia M, Zazzo JF. Nutrition and the Pancreas. Clin Nutr 2015. [DOI: 10.1002/9781119211945.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Role of Biomarkers in Diagnosis and Prognostic Evaluation of Acute Pancreatitis. J Biomark 2015; 2015:519534. [PMID: 26345247 PMCID: PMC4541003 DOI: 10.1155/2015/519534] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/14/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis is a potentially life threatening disease. The spectrum of severity of the illness ranges from mild self-limiting disease to a highly fatal severe necrotizing pancreatitis. Despite intensive research and improved patient care, overall mortality still remains high, reaching up to 30–40% in cases with infected pancreatic necrosis. Although little is known about the exact pathogenesis, it has been widely accepted that premature activation of digestive enzymes within the pancreatic acinar cell is the trigger that leads to autodigestion of pancreatic tissue which is followed by infiltration and activation of leukocytes. Extensive research has been done over the past few decades regarding their role in diagnosis and prognostic evaluation of severe acute pancreatitis. Although many standalone biochemical markers have been studied for early assessment of severity, C-reactive protein still remains the most frequently used along with Interleukin-6. In this review we have discussed briefly the pathogenesis and the role of different biochemical markers in the diagnosis and severity evaluation in acute pancreatitis.
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Staubli SM, Oertli D, Nebiker CA. Laboratory markers predicting severity of acute pancreatitis. Crit Rev Clin Lab Sci 2015; 52:273-83. [PMID: 26173077 DOI: 10.3109/10408363.2015.1051659] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute pancreatitis (AP) is an inflammatory disease of highly variable severity, ranging from mild cases with low mortality to severe cases with high mortality. Numerous biomarkers have been studied as potential early predictors of the severity of this disease so that treatment can be optimally tailored to prevent complications. We aim to present and discuss the most relevant biomarkers for early severity assessment in AP that have been studied to date. We review the current literature on biomarkers that have been used to predict the severity in AP. C-reactive protein (CRP) is still considered to be the gold standard, with a cut-off value of 150 mg/ml 48 h after disease onset. Other markers, including procalcitonin (PCT) and interleukin 6 (IL-6) have been implemented in some hospitals, but are not used on a routine basis. Most other markers, including acute phase proteins (LBP, SAA, PTX3), cytokines (Il-8, TNF-a, MIF), activation peptides of pancreatic proteases (TAP, CAPAP, PLAP), antiproteases (AAT, a2M), adhesion molecules (ICAM-1, selectins, E-cadherin) and leukocyte-derived enzymes (PA2, PMN-E) have shown some promising results but have not been routinely implemented. Furthermore, new and interesting biomarkers (Copeptin, TRX-1, Ang-2, E-2) have shown good results, but more research is needed to determine if they could play a role in the future. Various reasons why new markers for disease severity have not been adopted in daily routine include low accuracy, cumbersome laboratory techniques and high cost. Despite these difficulties, research is still very active in finding new markers to predict the severity of AP.
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Affiliation(s)
| | - Daniel Oertli
- a Department of General Surgery , University Hospital Basel , Basel , Switzerland
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Liu HH, Guo JB, Geng Y, Su L. Procalcitonin: present and future. Ir J Med Sci 2015; 184:597-605. [DOI: 10.1007/s11845-015-1327-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/20/2015] [Indexed: 12/15/2022]
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Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-32. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga.,Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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Yuan BS, Jin XX, Lu YK, Liu J, Wang SD, Wang ZK, Wu L, Wang FY. Clinical significance of serum procalcitonin in patients with ulcerative colitis. Shijie Huaren Xiaohua Zazhi 2015; 23:37-43. [DOI: 10.11569/wcjd.v23.i1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the association of serum procalcitonin (PCT) level with disease activity and inflammatory markers in ulcerative colitis (UC).
METHODS: Serum PCT levels, white blood cell count, platelet count, erythrocyte sedimentation rate (ESR), albumin, C-reactive protein (CRP) and interleukin-6 (IL-6) levels were analyzed in 31 patients with UC and 18 healthy volunteers. Severity assessments were based on the Truelove and Witts' severity index. Spearman's rank correlation and receiver operating characteristic (ROC) analysis were used to evaluate correlations between variables and diagnostic accuracy, respectively.
RESULTS: Serum PCT level in severe UC patients (n = 11, 0.426 μg/mL ± 0.506 μg/mL) was significantly higher than those in mild-to-moderate UC patients (n = 20, 0.079 μg/mL ± 0.085 μg/mL) and healthy volunteers (n = 18, 0.03 μg/mL ± 0.01 μg/mL) (P = 0.047, 0.027, respectively). Serum PCT level in UC patients was positively correlated with CRP levels, IL-6 levels and ESR, negatively with albumin levels (P < 0.05), but showed no statistically significant correlation with white blood cell count or platelet count (P > 0.05). PCT performed well in the prediction of UC, and was superior to CRP, ESR and white blood cell count for diagnosing severe UC. The area under the ROC curve was 0.895 (95%CI: 0.782-1.000, P < 0.001), 0.727 (95%CI: 0.548-0.906, P = 0.041), 0.856 (95%CI: 0.721-0.992, P = 0.001) and 0.665 (95%CI: 0.463-0.867, P = 0.138), respectively. A threshold of 0.1 μg/L for PCT may detect the most severe form of UC, and the sensitivity, specificity, predictive positive value and negative predictive value predictive were 90.91%, 80.00%, 71.43% and 94.12%, respectively.
CONCLUSION: Serum PCT level correlates with disease activity markers ESR and CRP in UC, and a cut-off of 0.1 μg/L could distinguish the most severe form of UC.
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Abstract
Sepsis is an important cause of worldwide morbidity and mortality. Early recognition and diagnosis are keys to achieving improved outcomes. Procalcitonin has been widely investigated as a potential biomarker for sepsis. Furthermore, management of sepsis and other infectious disease is becoming increasingly complicated by the emergence of antibiotic resistant strains of pathogens. Good antibiotic governance is important in reducing the risk of the development of further antibiotic resistance. We reviewed the current literature on the use of procalcitonin in sepsis to determine whether it should be recommended for use in either of these roles. Procalcitonin should not be used as a stand-alone diagnostic test to rule-in or rule-out sepsis or bacterial infection, or for prognostication, in the absence of clinical judgment. Used as part of a clinical algorithm, however, it has been shown to reduce antibiotic prescribing in critical care environments and for respiratory tract infections.
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A procalcitonin-based guideline promotes shorter duration of antibiotic use safely in acute pancreatitis. J Infect 2014; 69:412-5. [DOI: 10.1016/j.jinf.2014.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/17/2014] [Indexed: 11/22/2022]
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Talukdar R, Ingale P, Choudhury HP, Dhingra R, Shetty S, Joshi H, Pradeep KR, Mahapatra L, Mazumder S, Pradeep JK, Thakker B, Chaudhary A, Kumar A, Nageshwar Reddy D, Rao GV, Ramesh H, Bhat N, Garg P, Kochhar R. Antibiotic use in acute pancreatitis: an Indian multicenter observational study. Indian J Gastroenterol 2014; 33:458-65. [PMID: 25138788 DOI: 10.1007/s12664-014-0494-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/02/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Prophylactic antibiotics are used frequently for acute pancreatitis (AP). Consensus guidelines do not recommend this currently, based on moderate quality evidence. In this study, we aimed to evaluate the antibiotic use pattern in AP in India and propose a risk-directed approach to antibiotic use in AP. MATERIAL AND METHODS This multicenter study was conducted from 1 May 2013 to 31 July 2013. Eleven participants from eight tertiary centers completed a questionnaire that captured patient demographics, etiology, admission status, presence of (peri)pancreatic necrosis, severity of pancreatitis, details of antibiotic use, and clinical outcomes (total hospital stay, persistent organ failure, need for ICU, total days in ICU, development of infections, in-hospital mortality). RESULTS A total of 200 proformas were analyzed. Seventy-three (36.5 %) had acute necrotizing pancreatitis (ANP). Eighty-nine (44.5 %), 52 (26 %), and 55 (27.5 %) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. Forty-five (22.5 %) patients developed infections (unifocal 29; multifocal 16). One hundred thirty-four (67 %) patients received antibiotics, of which 89 (66.4 %) received prophylactic, while 45 (33.6 %) received therapeutic antibiotics. The distribution of antibiotic use according to the severity of AP was 43 (48.3 %) in patients with MAP (prophylactic in 41; therapeutic in 2), 36 (69.2 %) in patients with MSAP (prophylactic in 29; therapeutic in 7), and 55 (100 %) in patients with SAP (prophylactic in 19; therapeutic in 36). Therapeutic antibiotics were prescribed based on culture and sensitivity in 21 (46.7 %) patients. CONCLUSIONS Despite nonrecommendation, prophylactic antibiotics are used frequently in AP. We emphasize on the need for multicenter randomized controlled trials on prophylactic antibiotics for AP based on a risk-directed approach, rather than a "blanket approach."
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
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Silvestre J, Rebanda J, Lourenço C, Póvoa P. Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery - a pilot study. BMC Infect Dis 2014; 14:444. [PMID: 25132018 PMCID: PMC4143543 DOI: 10.1186/1471-2334-14-444] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/12/2014] [Indexed: 02/06/2023] Open
Abstract
Background Colorectal surgery is associated with postoperative infectious complications in up to 40% of cases, but the diagnosis of these complications is frequently misleading, delaying its resolution. Several biomarkers have been shown to be useful in infection diagnosis. Methods We conducted a single-centre, prospective, observational study segregating patients submitted to elective colorectal surgery with primary anastomosis, CRP and PCT were measured daily. We compared infected and non-infected patients. Results From October 2009 to June 2011, a total of 50 patients were included. Twenty-one patients developed infection. PCT and CRP before surgery were equally low in patients with or without postoperative infectious complications. After surgery, both PCT and CRP increased markedly. CRP time-course from the day of surgery onwards was significantly different in infected and non-infected patients (P = 0.001) whereas, PCT time-course was almost parallel in both groups (P = 0.866). Multiple comparisons between infected and non-infected patients from 5th to 9th postoperative days (POD) were performed and CRP concentration was significantly different (P < 0.01, Bonferroni correction), on the 6th, 7th and 8th POD. A CRP concentration > 5.0 mg/dl at the D6 was predictive of infection with a sensitivity of 85% and a specificity of 62% (positive likelihood ratio 2.2, negative likelihood ratio 0.2). Conclusions After a major elective surgical insult both CRP and PCT serum levels increased independently of the presence of infection. Besides serum CRP time-course showed to be useful in the early detection of an infectious complication whereas PCT was unhelpful. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-444) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joana Silvestre
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
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Mathew MJ, Parmar AK, Sahu D, Reddy PK. Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience. J Minim Access Surg 2014; 10:126-31. [PMID: 25013328 PMCID: PMC4083544 DOI: 10.4103/0972-9941.134875] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/24/2013] [Indexed: 12/13/2022] Open
Abstract
CONTEXT: Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management. AIMS: Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients. MATERIALS AND METHODS: A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach. RESULTS: The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period. CONCLUSIONS: Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.
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Affiliation(s)
- Mittu John Mathew
- Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Amit Kumar Parmar
- Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Diwakar Sahu
- Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Prasanna Kumar Reddy
- Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospital, Chennai, Tamil Nadu, India
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Dias BH, Rozario AP, Olakkengil SA, V A. Procalcitonin Strip Test as an Independent Predictor in Acute Pancreatitis. Indian J Surg 2014; 77:1012-7. [PMID: 27011501 DOI: 10.1007/s12262-014-1112-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/23/2014] [Indexed: 02/05/2023] Open
Abstract
Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infection and sepsis. Studies have demonstrated its role in the setting of sepsis and acute pancreatitis. This study aims to analyze and compare the prognostic efficacy of plasma procalcitonin strip test in acute pancreatitis. A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma procalcitonin was estimated by the semiquantitative strip test. The study included a total of 50 patients diagnosed to have acute pancreatitis. Data was collected and statistically analyzed using SPSS version 17. Thirty-nine out of the 50 patients (78 %) were males with a mean age of 46.8 years (range, 25-78 years) and 25 patients (50 %) had ethanol-induced pancreatitis, while 13 patients (26 %) had gall stone pancreatitis. Plasma PCT values were found to correlate better than CRP levels and total leukocyte count with the total duration of hospitalization, ITU, and ICU stay, as well as with the progression to severe acute pancreatitis. A cut off for plasma PCT of >2 ng/mL was found to be 100 % sensitive and 100 % specific and a cut off for CRP of >19 mg/dL was 70 % sensitive and 65 % specific for predicting the progression to severe acute pancreatitis. Plasma PCT also correlated well with antibiotic requirement. A cut off value of >0.5 ng/mL for plasma PCT was 100 % sensitive and 80 % specific and a cut off value of >18 mg/dL for CRP was 86 % sensitive and 63 % specific for predicting antibiotic requirement. Plasma procalcitonin is an early and reliable prognostic indicator in acute pancreatitis. The procalcitonin strip test is a rapid test which is useful in analyzing prognosis in patients with acute pancreatitis.
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Affiliation(s)
- Brendan Hermenigildo Dias
- Department of General Surgery, St. John's Medical College, St. John's Mens Hostel, Sarjapura road, Koramangala, Bangalore, India
| | - Anthony Prakash Rozario
- Department of General Surgery, St. John's Medical College Hospital, Sarjapura road, Koramangala, Bangalore, Karnataka India
| | - Santosh Antony Olakkengil
- Department of General Surgery, St. John's Medical College Hospital, Sarjapura road, Koramangala, Bangalore, Karnataka India
| | - Anirudh V
- Department of General Surgery, St. John's Medical College Hospital, Sarjapura road, Koramangala, Bangalore, Karnataka India
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Watkins RR, Lemonovich TL. Serum procalcitonin in the diagnosis and management of intra-abdominal infections. Expert Rev Anti Infect Ther 2014; 10:197-205. [DOI: 10.1586/eri.11.164] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hattori T, Nishiyama H, Kato H, Ikegami S, Nagayama M, Asami S, Usami M, Suzuki M, Murakami I, Minoshima M, Yamagishi H, Yuasa N. Clinical value of procalcitonin for patients with suspected bloodstream infection. Am J Clin Pathol 2014; 141:43-51. [PMID: 24343736 DOI: 10.1309/ajcp4gv7zfdtangc] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Procalcitonin (PCT) might be a useful marker to exclude bacteremia or to predict the severity of bacteremia and its outcome. However, most previous studies of PCT were limited to particular patient populations. In addition, reports about PCT levels in patients with renal dysfunction have been conflicting. We investigated the predictive value of PCT in an unselected population with suspected bloodstream infections and also assessed the relationship between PCT and renal function. METHODS We retrospectively analyzed medical records of 1,331 patients (age ≥1 8 years) with suspected bloodstream infections who had concurrent biochemical data and blood culture results. RESULTS The PCT level was significantly elevated in patients with positive blood cultures, and it showed a significant relation with survival in patients with bacteremia. The optimal cutoff value of PCT for predicting a positive blood culture showed an increase as the estimated glomerular filtration rate declined. CONCLUSION PCT can be a useful marker to exclude bacteremia and also to predict severe bacteremia, but renal function should be taken into account.
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Affiliation(s)
- Takuya Hattori
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hideki Nishiyama
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hideki Kato
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shinobu Ikegami
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Madoka Nagayama
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Saori Asami
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Miyuki Usami
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Mayuko Suzuki
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Itsuka Murakami
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Makoto Minoshima
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hiroe Yamagishi
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Norihiro Yuasa
- Department of Clinical Laboratory, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
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Mahamadoun C, Nawfal H, Brahim B, Sbai H, Nabil K. [Superinfected pancreatitis revealed by psoas abscess]. Pan Afr Med J 2014; 19:387. [PMID: 25995783 PMCID: PMC4430037 DOI: 10.11604/pamj.2014.19.387.4360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 10/02/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Houari Nawfal
- Service de Réanimation Polyvalente A4, CHU Hassan 2 de Fès, Maroc
| | - Boukatta Brahim
- Service de Réanimation Polyvalente A4, CHU Hassan 2 de Fès, Maroc
| | - Hicham Sbai
- Service de Réanimation Polyvalente A4, CHU Hassan 2 de Fès, Maroc
| | - Kanjaa Nabil
- Service de Réanimation Polyvalente A4, CHU Hassan 2 de Fès, Maroc
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Jung B, Molinari N, Nasri M, Hajjej Z, Chanques G, Jean-Pierre H, Panaro F, Jaber S. Procalcitonin biomarker kinetics fails to predict treatment response in perioperative abdominal infection with septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R255. [PMID: 24156734 PMCID: PMC4056026 DOI: 10.1186/cc13082] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/11/2013] [Indexed: 02/05/2023]
Abstract
Introduction Procalcitonin (PCT) biomarker is suggested to tailor antibiotic therapy in the medical intensive care unit (ICU) but studies in perioperative medicine are scarce. The aim of this study was to determine whether PCT reported thresholds are associated with the initial treatment response in perioperative septic shock secondary to intra-abdominal infection. Methods This single ICU, observational study included patients with perioperative septic shocks secondary to intra-abdominal infection. Demographics, PCT at days 0, 1, 3, 5, treatment response and outcome were collected. Treatment failure included death related to the initial infection, second source control treatment or a new onset intra-abdominal infection. The primary endpoint was to assess whether PCT thresholds (0.5 ng/ml or a drop from the peak of at least 80%) predict the initial treatment response. Results We included 101 consecutive cases. Initial treatment failed in 36 patients with a subsequent mortality of 75%. Upon admission, PCT was doubled when treatment ultimately failed (21.7 ng/ml ± 38.7 vs. 41.7 ng/ml ± 75.7; P = 0.04). Although 95% of the patients in whom PCT dropped down below 0.5 ng/ml responded to treatment, 50% of the patients in whom PCT remained above 0.5 ng/ml also responded successfully to treatment. Moreover, despite a PCT drop of at least 80%, 40% of patients had treatment failure. Conclusions In perioperative intra-abdominal infections with shock, PCT decrease to 0.5 ng/ml lacked sensitivity to predict treatment response and its decrease of at least 80% from its peak failed to accurately predict treatment response. Studies in perioperative severe infections are needed before using PCT to tailor antibiotic use in this population.
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Early angiopoietin-2 levels after onset predict the advent of severe pancreatitis, multiple organ failure, and infectious complications in patients with acute pancreatitis. J Am Coll Surg 2013; 218:26-32. [PMID: 24355874 DOI: 10.1016/j.jamcollsurg.2013.09.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/31/2013] [Accepted: 09/30/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute pancreatitis is a severe condition that requires early identification of patients at risk of developing potentially lethal complications. Current clinical scoring systems and biochemical parameters are insufficient. In this study, we aimed to assess whether early plasma Angiopoietin-2 (Ang-2) is associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP). STUDY DESIGN This analysis is a substudy of the PROPATRIA trial (probiotics vs placebo in patients with predicted SAP). The Ang-2 levels were measured prospectively in plasma in the first 5 days after admission in 115 patients. RESULTS Early Ang-2 levels were higher in patients who developed SAP: 6.4 vs 3.1 μg/L (p < 0.001) and also were higher in patients who developed multiorgan failure in the first week (p = 0.001) and after the first week (p = 0.049). Furthermore, high Ang-2 levels were associated with infectious complications in the first week (p < 0.001) and after the first week (p < 0.001). Finally, plasma Ang-2 was significantly higher in patients who died (p < 0.001) and in patients who developed bowel ischemia (p < 0.001). As a predictor of adverse outcomes, plasma Ang-2 was superior to a number of current scores, such as the APACHE II score, the Imrie score, C-reactive protein, lipopolysaccharide binding protein, and procalcitonin. CONCLUSIONS In the setting of this randomized controlled trial, early plasma Ang-2 was found to be an accurate predictor of SAP, multiorgan failure, and infectious complications. As a biomarker, it did outperform all of the investigated conventional predictors that are currently used in clinical practice.
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93
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Kinetics of procalcitonin and C-reactive protein and the relationship to postoperative infection in young infants undergoing cardiovascular surgery. Pediatr Res 2013; 74:413-9. [PMID: 23863853 PMCID: PMC3955993 DOI: 10.1038/pr.2013.124] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 03/09/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The utility of procalcitonin (PCT) and C-reactive protein (CRP) as infectious biomarkers following infant cardiothoracic surgery is not well defined. METHODS We designed a prospective cohort study to evaluate PCT and CRP after infant cardiothoracic surgery. PCT and CRP were drawn preoperatively and 24/72 h postoperation or daily in delayed sternal closure patients. Presence of infection within 10 d of surgery, vasoactive-inotropic scores at 24 and 72 h, and length of intubation, intensive care unit stay, and hospital stay were documented. RESULTS PCT and CRP were elevated at 24 h. PCT then decreased while CRP increased in patients undergoing delayed sternal closure or cardiopulmonary bypass. In the delayed sternal closure group, PCT was significantly higher on postoperative days 2-5 in patients who ultimately developed infection. Higher PCT was independently associated with increased vasoactive-inotropic score at 72 h. CRP did not correlate with infection or postoperative support. CONCLUSION PCT rises after cardiothoracic surgery in infants but decreases by 72 h while CRP remains elevated. Sternal closure may affect CRP but not PCT. PCT is independently associated with circulatory support requirements at 72 h postoperation and with development of infection. PCT may have greater utility as a biomarker in this population.
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94
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Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2013; 2013:367581. [PMID: 24204087 PMCID: PMC3800571 DOI: 10.1155/2013/367581] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 08/28/2013] [Indexed: 02/07/2023]
Abstract
Background. Multifactorial scorings, radiological scores, and biochemical markers may help in early prediction of severity, pancreatic necrosis, and mortality in patients with acute pancreatitis (AP).
Methods. BISAP, APACHE-II, MOSS, and SIRS scores were calculated using data within 24 hrs of admission, whereas Ranson and Glasgow scores after 48 hrs of admission; CTSI was calculated on day 4 whereas IL-6 and CRP values at end of study. Predictive accuracy of scoring systems, sensitivity, specificity, and positive and negative predictive values of various markers in prediction of severe acute pancreatitis, organ failure, pancreatic necrosis, admission to intensive care units and mortality were calculated. Results. Of 72 patients, 31 patients had organ failure and local complication classified as severe acute pancreatitis, 17 had pancreatic necrosis, and 9 died (12.5%). Area under curves for Ranson, Glasgow, MOSS, SIRS, APACHE-II, BISAP, CTSI, IL-6, and CRP in predicting SAP were 0.85, 0.75, 0.73, 0.73, 0.88, 0.80, 0.90, and 0.91, respectively, for pancreatic necrosis 0.70, 0.64, 0.61, 0.61, 0.68, 0.61, 0.75, 0.86, and 0.90, respectively, and for mortality 0.84, 0.83, 0.77, 0.76, 0.86, 0.83, 0.57, 0.80, and 0.75, respectively. Conclusion. CRP and IL-6 have shown a promising result in early detection of severity and pancreatic necrosis whereas APACHE-II and Ranson score in predicting AP related mortality in this study.
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95
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Quenot JP, Luyt CE, Roche N, Chalumeau M, Charles PE, Claessens YE, Lasocki S, Bedos JP, Péan Y, Philippart F, Ruiz S, Gras-Leguen C, Dupuy AM, Pugin J, Stahl JP, Misset B, Gauzit R, Brun-Buisson C. Role of biomarkers in the management of antibiotic therapy: an expert panel review II: clinical use of biomarkers for initiation or discontinuation of antibiotic therapy. Ann Intensive Care 2013; 3:21. [PMID: 23830525 PMCID: PMC3716933 DOI: 10.1186/2110-5820-3-21] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 06/08/2013] [Indexed: 12/13/2022] Open
Abstract
Biomarker-guided initiation of antibiotic therapy has been studied in four conditions: acute pancreatitis, lower respiratory tract infection (LRTI), meningitis, and sepsis in the ICU. In pancreatitis with suspected infected necrosis, initiating antibiotics best relies on fine-needle aspiration and demonstration of infected material. We suggest that PCT be measured to help predict infection; however, available data are insufficient to decide on initiating antibiotics based on PCT levels. In adult patients suspected of community-acquired LRTI, we suggest withholding antibiotic therapy when the serum PCT level is low (<0.25 ng/mL); in patients having nosocomial LRTI, data are insufficient to recommend initiating therapy based on a single PCT level or even repeated measurements. For children with suspected bacterial meningitis, we recommend using a decision rule as an aid to therapeutic decisions, such as the Bacterial Meningitis Score or the Meningitest®; a single PCT level ≥0.5 ng/mL also may be used, but false-negatives may occur. In adults with suspected bacterial meningitis, we suggest integrating serum PCT measurements in a clinical decision rule to help distinguish between viral and bacterial meningitis, using a 0.5 ng/mL threshold. For ICU patients suspected of community-acquired infection, we do not recommend using a threshold serum PCT value to help the decision to initiate antibiotic therapy; data are insufficient to recommend using PCT serum kinetics for the decision to initiate antibiotic therapy in patients suspected of ICU-acquired infection. In children, CRP can probably be used to help discontinue therapy, although the evidence is limited. In adults, antibiotic discontinuation can be based on an algorithm using repeated PCT measurements. In non-immunocompromised out- or in- patients treated for RTI, antibiotics can be discontinued if the PCT level at day 3 is < 0.25 ng/mL or has decreased by >80-90%, whether or not microbiological documentation has been obtained. For ICU patients who have nonbacteremic sepsis from a known site of infection, antibiotics can be stopped if the PCT level at day 3 is < 0.5 ng/mL or has decreased by >80% relative to the highest level recorded, irrespective of the severity of the infectious episode; in bacteremic patients, a minimal duration of therapy of 5 days is recommended.
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Affiliation(s)
- Jean-Pierre Quenot
- Service de Réanimation médicale, Hôpitaux Universitaires Henri Mondor, AP-HP & Université Paris-Est, 51, av de Lattre de Tassigny, 94000 Créteil, France.
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96
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Maraví-Poma E, Patchen Dellinger E, Forsmark CE, Layer P, Lévy P, Shimosegawa T, Siriwardena AK, Uomo G, Whitcomb DC, Windsor JA, Petrov MS. [International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]. Med Intensiva 2013; 38:211-7. [PMID: 23747189 DOI: 10.1016/j.medin.2013.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- E Maraví-Poma
- UCI-B, Complejo Hospitalario de Navarra (antiguo Hospital Virgen del Camino), Pamplona, España.
| | - E Patchen Dellinger
- Department of Surgery, University of Washington School of Medicine, Seattle, Estados Unidos
| | - C E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, Estados Unidos
| | - P Layer
- Department of Internal Medicine, Israelitic Hospital, Hamburgo, Alemania
| | - P Lévy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, Clichy, Francia
| | - T Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japón
| | - A K Siriwardena
- Department of Surgery, Manchester Royal Infirmary, University of Manchester, Manchester, Reino Unido
| | - G Uomo
- Department of Internal Medicine, Cardarelli Hospital, Nápoles, Italia
| | - D C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Department of Cell Biology and Molecular Physiology, Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, Estados Unidos
| | - J A Windsor
- Department of Surgery, University of Auckland, Miembro International Association of Pancreatology, Auckland, Nueva Zelanda
| | - M S Petrov
- Department of Surgery, University of Auckland, Miembro International Association of Pancreatology, Auckland, Nueva Zelanda
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Talukdar R, Nechutova H, Clemens M, Vege SS. Could rising BUN predict the future development of infected pancreatic necrosis? Pancreatology 2013; 13:355-9. [PMID: 23890133 DOI: 10.1016/j.pan.2013.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 05/08/2013] [Accepted: 05/09/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infected (peri)pancreatic necrosis (IPN) in acute pancreatitis (AP) is associated with organ failure (OF) and high mortality. There are no established early markers of primary IPN. This study aimed to assess the association of simple parameters with primary IPN in AP. METHODS We retrospectively studied 281 patients with AP admitted to Mayo Clinic hospitals and identified those with microbiologically confirmed infections in (peri)pancreatic necrosis and collections. We defined primary IPN as infection of (peri)pancreatic necrotic tissue that developed before interventions. We recorded admission hematocrit, BMI, BUN, serum creatinine, SIRS score and development of persistent organ failure within 48 h of admission; and performed serial SIRS and BUN calculations for at least 48 h. We used univariate and multivariable analysis to assess associations and expressed results as odds ratio (OR)[95% CI]. RESULTS 27 (9.6%) patients developed IPN, of which 21 (77.7%) had primary IPN. 38.1% had Gram positive, 9.5% Gram negative and 52.3% mixed bacterial infections. Five (23.8%) of the patients with IPN had fungal infection. On univariate analysis, SIRS ≥ 2 at admission, rise in BUN by 5 mg/dL within 48 h of admission, persistence of SIRS for 48 h and development of persistent OF within 48 h of disease had significant association with development of primary IPN with OR (95% CI) of 4.12 (1.53-11.15), 10.25 (3.95-26.61), 1.19 (1.69-10.39) and 7.62 (2.58-21.25) [2-tailed p = 0.004, <0.0001, 0.002 and <0.0001] respectively. On multivariable analysis, only rise in BUN by 5 mg/dL within 48 h of admission was associated with primary IPN (p = 0.007). CONCLUSIONS Rising BUN within 48 h of admission can be used to predict development of primary IPN in AP.
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Affiliation(s)
- Rupjyoti Talukdar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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98
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Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, Jang JS, Lee JH, Choi SR, Park BH. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med 2013; 28:322-9. [PMID: 23682226 PMCID: PMC3654130 DOI: 10.3904/kjim.2013.28.3.322] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/19/2012] [Accepted: 07/19/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND/AIMS The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic multifactorial scoring system. As more data are needed before clinical application, we compared BISAP, the serum procalcitonin (PCT), and other multifactorial scoring systems simultaneously. METHODS Fifty consecutive acute pancreatitis patients were enrolled prospectively. Blood samples were obtained at admission and after 48 hours and imaging studies were performed within 48 hours of admission. The BISAP score was compared with the serum PCT, Ranson's score, and the acute physiology and chronic health examination (APACHE)-II, Glasgow, and Balthazar computed tomography severity index (BCTSI) scores. Acute pancreatitis was graded using the Atlanta criteria. The predictive accuracy of the scoring systems was measured using the area under the receiver-operating curve (AUC). RESULTS The accuracy of BISAP (≥ 2) at predicting severe acute pancreatitis was 84% and was superior to the serum PCT (≥ 3.29 ng/mL, 76%) which was similar to the APACHE-II score. The best cutoff value of BISAP was 2 (AUC, 0.873; 95% confidence interval, 0.770 to 0.976; p < 0.001). In logistic regression analysis, BISAP had greater statistical significance than serum PCT. CONCLUSIONS BISAP is more accurate for predicting the severity of acute pancreatitis than the serum PCT, APACHE-II, Glasgow, and BCTSI scores.
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Affiliation(s)
- Byung Geun Kim
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Myung Hwan Noh
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Choong Heon Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Hwa Seong Nam
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Su Mi Woo
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Seung Hee Ryu
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jin Seok Jang
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hun Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Seok Ryeol Choi
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Byeong Ho Park
- Department of Radiology, Dong-A University College of Medicine, Busan, Korea
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99
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Talukdar R, Nageshwar Reddy D. Predictors of adverse outcomes in acute pancreatitis: new horizons. Indian J Gastroenterol 2013; 32:143-51. [PMID: 23475525 DOI: 10.1007/s12664-013-0306-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 02/03/2013] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India.
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The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR. J Gastrointest Surg 2013; 17:675-81. [PMID: 23371356 DOI: 10.1007/s11605-012-2121-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 12/06/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The neutrophil-lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction. MATERIALS AND METHODS NLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification. RESULTS One hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3 days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63-90 %, specificities of 50-57 %, negative predictive value of 89.5-96.4 %, positive predictive values of 21.2-31.1 %, and accuracies of 57.7-60 %. CONCLUSIONS Elevation of the NLR during the first 48 h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.
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