Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

Reactive oxygen species induced by bile acid induce apoptosis and protect against necrosis in pancreatic acinar cells

BACKGROUND & AIMS

Oxidative stress is implicated in the pathogenesis of pancreatitis, but clinical trials of antioxidants have produced conflicting results. We examined the role of intracellular reactive oxygen species (ROS) in pancreatic acinar cell injury.

METHODS

Freshly isolated murine and human pancreatic acinar cells were studied using confocal microscopy to measure changes in intracellular and mitochondrial ROS concentrations ([ROS]I and [ROS]M), cytosolic and mitochondrial calcium concentrations ([Ca2+]C and [Ca2+]M), reduced nicotinamide adenine dinucleotide phosphate levels, and death pathways in response to taurolithocholate acid sulfate (TLC-S) or the oxidant menadione. Ca2+-activated Cl- currents were measured using whole-cell patch clamp, with or without adenosine triphosphate (ATP).

RESULTS

TLC-S induced prolonged increases in [Ca2+]C and [Ca2+]M, which led to dose-dependent increases in [ROS]I and [ROS]M, impaired production of ATP, apoptosis, and necrosis. Inhibition of the antioxidant reduced nicotinamide adenine dinucleotide phosphate quinine oxidoreductase by 2,4-dimethoxy-2-methylnaphthalene potentiated the increases in [ROS]I and apoptosis but reduced necrosis, whereas the antioxidant N-acetyl-L-cysteine reduced [ROS]I and apoptosis but increased necrosis. Inhibition of mitochondrial ROS production prevented apoptosis but did not alter necrosis; autophagy had no detectable role. Patched ATP prevented sustained increases in [Ca2+]C and necrosis.

CONCLUSIONS

Increases in [ROS]M and [ROS]I during bile acid injury of pancreatic acinar cells promote apoptosis but not necrosis. These results indicate that alternative strategies to antioxidants are required for oxidative stress in acute pancreatitis.

Discrepancy between the extent of pancreatic necrosis and multiple organ failure score in severe acute pancreatitis

BACKGROUND

Whether pancreatic necrosis is a prerequisite for the development of multiorgan failure (MOF) in severe acute pancreatitis (AP) is not clear and has implications for the rational design of translational therapies. This study was designed to investigate the magnitude of any association between MOF and radiologically evident pancreatic or extrapancreatic complications of AP.

METHODS

Data regarding 276 patients with AP were analyzed retrospectively with regard to clinical presentation, MOF severity, computerized tomography (CT) evidence of pancreatic necrosis, and modified CT severity index (MCTSI).

RESULTS

Agreement between the presence of necrosis and MOF status was seen in 160 of 276 patient episodes (58%; 95% confidence intervals (CI), 52.1-63.8%). In 116 of 276 episodes, the MCTSI and MOF scores disagreed (42%; 95% CI, 36.2-47.9%). CT evidence of pancreatic necrosis was present in 21 of 104 (20.2%) patients without any evidence of MOF, and there was no evidence of necrosis on CT scan in 95 of 176 (54%) patients with MOF. Full-factorial univariate analysis suggested that extrapancreatic complications seen on CT, in particular intra-abdominal fluid collections (effect size = 0.02; P = 0.016) and abnormal liver enhancement (effect size = 0.035; P = 0.031) were associated with severity of MOF, and exerted an even greater effect when they occurred synchronously.

CONCLUSIONS

The discrepancy between the presence of necrosis and the occurrence of MOF favors association but not cause in AP. A complex, systems-based, pleiotropic inflammatory network with a common root, in which the extent of pancreatic necrosis influences the severity of MOF in certain individuals and MOF exacerbates the development of pancreatic necrosis in others, seems more likely.

Progress in the management of necrotizing pancreatitis

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Primary conservative treatment results in mortality comparable to surgery in patients with infected pancreatic necrosis

BACKGROUND & AIMS

The standard treatment for patients with infected pancreatic necrosis (IPN) is surgical necrosectomy. We compared the outcomes of surgical treatment versus primary conservative treatment (patients kept in intensive care unit and treated with antibiotics, organ support, intensive nutritional support, and, if required, percutaneous drainage) among patients with IPN.

METHODS

We performed retrospective comparative (with prospectively acquired database) and prospective observational studies; data were collected from all consecutive patients with acute pancreatitis (n = 804), and those with IPN formed the study group. Patients with IPN were divided into 2 groups on the basis of diagnosis of IPN during 1997-2002 (group 1, n = 30) or 2003-2006 (group 2, n = 50). Eighteen patients in group 1 were treated by surgical necrosectomy, and 40 patients in group 2 were given primary conservative treatment; surgery was performed on patients if conservative treatment failed (n = 10). The primary outcome measure was mortality.

RESULTS

The mortality was comparable in group 1 versus group 2 (43% vs 28%; P = .22). During a period of 10 years, the patients who received primary conservative treatment had significantly higher survival rates than those who received surgery (76.9% vs 46.4%; P = .005). In the prospective study during 2007-2008, the mortality from infected necrosis was 29.6% after primary conservative treatment, confirming the results of the comparative study.

CONCLUSIONS

In treating patients with IPN, a primary conservative strategy resulted in mortality that was comparable with that after surgery, and 76% of the patients were able to avoid surgery; 54.5% of IPN patients were successfully managed with the primary conservative strategy.

Infected pancreatic necrosis: minimizing the cut

The challenge for the pancreatologist managing patients with infected pancreatic necrosis is to devise a treatment algorithm that enables recovery but at the same time limits the morbidity and mortality. The current gold standard remains open necrosectomy. Recent literature contains scattered reports of endoscopic, radiologic, laparoscopic, percutaneous and lumbotomy approaches to managing patients with this condition. This literature review addresses the role of techniques that aim to minimize the physiological insult to the patient with infected pancreatic necrosis.

Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis

BACKGROUND & AIMS

There is no consistency between the individual studies in the literature on whether organ failure (OF) or infected pancreatic necrosis (IPN) is the main determinant of severity in acute pancreatitis. We aimed to statistically aggregate the available data and determine the pooled influence of OF and IPN on mortality in patients with acute pancreatitis.

METHODS

The search for relevant observational studies was undertaken in the MEDLINE, EMBASE, and Scopus electronic databases, as well as in the proceedings of major gastroenterology meetings. The summary estimates are presented as relative risk (RR) and 95% confidence interval (CI).

RESULTS

Fourteen studies comprising 1478 patients with acute pancreatitis were meta-analyzed. A total of 600 patients developed OF and 179 of them died (mortality, 30%); 314 patients developed IPN and 102 of them died (mortality, 32%). In a stratified analysis, patients with OF and IPN had a significantly higher risk of death in comparison with patients with OF and no IPN (RR = 1.94; 95% CI: 1.32-2.85; P = .0007) and in comparison with patients with IPN and no OF (RR = 2.65; 95% CI: 1.30-5.40; P = .0007).

CONCLUSIONS

In patients with acute pancreatitis, the absolute influence of OF and IPN on mortality is comparable and thus the presence of either indicates severe disease. The relative risk of mortality doubles when OF and IPN are both present and indicates extremely severe disease or critical acute pancreatitis.

Classification of the severity of acute pancreatitis: how many categories make sense?

There is an ongoing effort to revise the 1992 Atlanta classification of acute pancreatitis in the light of emerging evidence. The categorization of the severity of acute pancreatitis is one of the key elements of the classification. This paper aims to define the optimal number of categories and provide their definitions on sound clinical grounds.

Severe acute pancreatitis: overall and early versus late mortality in intensive care units

OBJECTIVES

To determine overall mortality and timing of death in patients with severe acute pancreatitis and factors affecting mortality.

METHODS

This was a retrospective, observational study of 110 patients admitted to a general intensive care unit (ICU) from January 2003 to January 2006.

RESULTS

The overall mortality rate was 53.6% (59/110); 25.4% (n = 15) of deaths were early (

CONCLUSIONS

Overall mortality and median APACHE II score were high. Death predominantly occurred late and was unaffected by patient age, length of stay in the ICU, or surgical/medical treatment. An APACHE II cutoff of 24.5 and pre-ICU admission time of 2.5 days were sensitive predictors of fatal outcome.

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MESH Headings

• APACHE
• Acute Disease
• Adult
• Aged
• Female
• Humans
• Intensive Care Units
• Male
• Middle Aged
• Pancreatitis/mortality
• Pancreatitis/surgery
• Retrospective Studies

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Affiliation(s)

Vesna Bumbasirevic Clinical Center of Serbia, Belgrade, Serbia
Dejan Radenkovic
Zorica Jankovic
Aleksandar Karamarkovic
Bojan Jovanovic
Natasa Milic
Ivan Palibrk
Nenad Ivancevic

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Ischemic acute pancreatitis: clinical features of 11 patients and review of the literature

BACKGROUND

Besides alcohol and gallstones, pancreatic ischemia can cause acute pancreatitis (AP). This entity should be considered when no other reasons can be defined. The aim of the current study was to define ischemic AP with its pathophysiologic, radiologic, and clinical conditions.

METHODS

Eleven patients with ischemic AP of different origin were analyzed regarding course, severity, and outcome, as well as diagnostic and therapeutic measures.

RESULTS

Ischemic AP was caused by hemorrhage and hypotension (7 patients) or mesenteric macrovessel occlusion (4 patients). Therapy was conservative (4 patients) or operative with hemostasis, necrosectomy, and drainage (7 patients). Seven patients died within 38 days, and 4 patients recovered.

CONCLUSION

Pancreatic hypoperfusion is an important etiology of AP. Severity of the disease ranges from moderate reversible changes to severe courses with fatal outcome. The indication for surgical intervention in ischemic AP is more aggressive; diagnostic and conservative therapeutic procedures are similar to AP of other etiologies.

Management of infected pancreatic necrosis

The past two decades have seen major advances in the understanding and clinical management of acute pancreatitis, yet it still lacks a specific treatment, and management is largely supportive and reactive. Surgery is seeing a diminishing role in the early phase of acute pancreatitis but still predominates in the management of infected pancreatic necrosis--the most lethal complication. This review focuses on recent literature but begins with an account of the evolution of infected necrosis management, which serves to place current treatment into context. Although surgeons initially emphasized less invasive approaches to pancreatic necrosis, they now compete with new techniques developed by pioneering physicians, radiologists, and interventional endoscopists. Clinicians adopting the new techniques will need to emulate the dedication and commitment that the current pioneers demonstrate. Although new techniques are still evolving, they should be evaluated against existing standards of treatment.

Protocol-based medical management of post-ERCP pancreatitis

BACKGROUND AND AIMS

Although numerous studies have evaluated outcomes pertaining to endoscopic retrograde cholangio-pancreatography (ERCP) complications, studies evaluating outcomes of management of post-ERCP pancreatitis are scant. This study evaluated the effectiveness of a standard treatment protocol in management of post-ERCP pancreatitis.

METHODS

This is a retrospective study of consecutive patients managed for post-ERCP pancreatitis, using a standard treatment protocol over a 3-year period. By protocol, patients received only intravenous fluids, narcotics, and analgesics for the first 24-72 h after admission. Oral intake was attempted when white cell count was normal or followed a downward trend, abdominal pain was absent or minimal without need for narcotics over a 12-h period, and serum lipase was less than three times normal range. For patients hospitalized beyond 72 h, an abdomen CT was obtained at days 4 and 10 to guide management. Intravenous antibiotics were administered only for patients with pancreatic necrosis. Jejunal feeding and a meperidine pump for pain control were initiated in symptomatic patients at day 4. Data on ERCP complications were collected prospectively and graded per consensus criteria. Effectiveness of the treatment protocol was evaluated by comparing clinical outcomes of patients managed by protocol versus those managed outside protocol.

RESULTS

45 of 1976 patients (2.3%) who underwent ERCP developed post-ERCP pancreatitis. Of the 45 (female 31; mean age 43 years) patients, 32 were managed by protocol and 13 outside protocol. Protocol based management was associated with less severe disease as compared with those managed outside protocol (crude odds ratio (OR) = 11.2; 95% confidence interval (CI) = 1.9-68.7; P = 0.002). One patient managed outside protocol died of severe pancreatitis. When compared with those managed outside protocol, the median duration of hospital stay (7 vs 3 days; P = 0.01), the use of CT (100% vs 15.6%; P < 0.001), and the use of antibiotics (50% vs 3.1%; P = 0.01) were significantly lower in those managed by protocol. By multiple logistic regression, protocol-based management was associated with less severe disease (adjusted OR = 18.7; 95% CI = 2.6-132.1; P = 0.003) when adjusted for age, comorbidity, endotherapy and pancreatic stenting.

CONCLUSIONS

A protocol-based management strategy was associated with less severe pancreatitis, shorter length of hospital stay, need for fewer imaging studies, and use of antibiotics. Prospective validation of these findings is justified.

Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure?

OBJECTIVE

To define the magnitude, causes, risk factors, and consequences of hemorrhage in acute pancreatitis (AP).

METHODS

Consecutive patients with AP were studied for hemorrhagic complication and its impact on mortality. Patients with gastrointestinal (GI) hemorrhage or hemorrhage within the pancreatic bed were managed with transfusions, endotherapy, angiographic embolization, or surgery as appropriate.

RESULTS

Of 449 patients, 28 (6.2%) developed hemorrhage. The mean age of patients with hemorrhage was 39 +/- 14 years and 25 (89%) were men. Of the 28 patients, 16 had GI hemorrhage, and 12 had hemorrhage into the pancreatic bed. Median interval between the onset of AP and hemorrhage was 26.5 days. Pancreatic necrosis, sepsis, fluid collection, and organ failure were found to be risk factors for hemorrhage. Five patients had pseudoaneurysms; angiographic embolization was successful in 4 of them. The mortality rate in bleeders was higher than that in nonbleeders (28.6% vs 13%; P = 0.02). None of the patients died as a direct consequence of hemorrhage except 1 patient who died after surgery for failed embolization of bleeding pseudoaneurysm. Deaths were mainly caused by sepsis and multiorgan failure.

CONCLUSIONS

Hemorrhagic complications are usually late manifestations in the course of severe pancreatitis and per se have little bearing on mortality.

Markers for predicting severity and progression of acute pancreatitis

Several tools have been developed for severity stratification in acute pancreatitis. They include single biochemical markers, imaging methods, and complex scoring systems, all of which aim at an early detection of severe acute pancreatitis to optimise monitoring and treatment of patients as early as possible. Among single biochemical markers, C-reactive protein (CRP) remains the most useful. Despite its delayed increase, peaking not earlier than 72 h after the onset of symptoms, it is accurate and widely available. Many other markers have been evaluated for their usefulness, and for some of them very promising data could be shown. Among them interleukin 6 seems to be the most promising parameter for use in clinical routine. For the detection of pancreatic infection, procalcitonin is the most sensitive, and can be used as an indicator for the need for fine-needle aspiration of pancreatic necrosis. Regarding imaging, contrast-enhanced computed tomography is still the reference method for the detection of necrotising acute pancreatitis. Pancreatitis-specific scoring systems have been shown to be of value for the prediction of severity and progression of acute pancreatitis, but cannot be applied any earlier than 48 h after admission to hospital. The APACHE-II score has not been developed specifically for acute pancreatitis and is rather complex to assess, but has been proven to be an early and reliable tool. Indication, timing and consequences of the methods applied need to be carefully considered and incorporated into clinical assessments to avoid costs and harm to the patient.

The Atlanta Classification of acute pancreatitis revisited

BACKGROUND

In a complex disease such as acute pancreatitis, correct terminology and clear definitions are important. The clinically based Atlanta Classification was formulated in 1992, but in recent years it has been increasingly criticized. No formal evaluation of the use of the Atlanta definitions in the literature has ever been performed.

METHODS

A Medline literature search sought studies published after 1993. Guidelines, review articles and their cross-references were reviewed to assess whether the Atlanta or alternative definitions were used.

RESULTS

A total of 447 articles was assessed, including 12 guidelines and 82 reviews. Alternative definitions of predicted severity of acute pancreatitis, actual severity and organ failure were used in more than half of the studies. There was a large variation in the interpretation of the Atlanta definitions of local complications, especially relating to the content of peripancreatic collections.

CONCLUSION

The Atlanta definitions for acute pancreatitis are often used inappropriately, and alternative definitions are frequently applied. Such lack of consensus illustrates the need for a revision of the Atlanta Classification.

Characterization of newer subgroups of fulminant and subfulminant pancreatitis associated with a high early mortality

BACKGROUND

Risk stratification of acute pancreatitis (AP) is important.

OBJECTIVE

To characterize patients with early severe pancreatitis, identify risk factors of severity, and assess their outcome.

METHODS

All consecutive patients with AP were included in the study. Severity assessment was done by APACHE II score, and presence and intensity of organ failure (OF). OF was graded from 1 to 4. Patients with severe pancreatitis were divided into early severe and late severe AP. The criterion for early severe AP (ESAP) was severe OF within 7 days of pancreatitis. Patients with ESAP were subdivided into fulminant and subfulminant AP based on timing of OF, i.e., <72 h and between 4 and 7 days of pancreatitis, respectively.

RESULTS

Of 282 patients with AP, 144 (51%) had mild AP, 32 (11.34%) had ESAP, and 106 (37.58%) had late severe AP. Of the ESAP patients (mean age 45.4 yr, 22 men), 10 patients had fulminant AP and 22 had subfulminant AP. Patients with ESAP had higher admission APACHE II compared to patients with late severe AP (14.9 vs 8.8, P<0.001). The proportion of patients with multiorgan failure was significantly higher in ESAP compared with late severe AP (75%vs 26%, P<0.001). The difference in mortality was significant in the fulminant, subfulminant, and late severe AP (90%, 72.7%, and 30%; P<0.001). Patients with ESAP accounted for 44% of all deaths. Predictors of mortality were development and early onset of organ failure.

CONCLUSIONS

We have characterized newer subgroups of patients with fulminant and subfulminant AP with important prognostic and management implications.

Diagnostic assessment and outcome of acute pancreatitis in Italy: results of a prospective multicentre study. ProInf-AISP: Progetto informatizzato pancreatite acuta, Associazione Italiana Studio Pancreas, phase II

BACKGROUND AND AIM

Up till now, only one study providing practically complete information on acute pancreatitis in Italy has been published. The aim of this prospective study was to evaluate the clinical characteristics, in terms of diagnostic assessment and outcome, of a large series of patients affected by acute pancreatitis in Italy.

MATERIALS AND METHODS

The study involved 56 Italian centres, homogeneously distributed throughout the entire national territory. Each participating centre was furnished with an ad hoc software including 530 items along with subsequent collection, tabulation and quality control of the data.

RESULTS

One thousand five hundred and forty case report forms of patients affected by acute pancreatitis were collected but 367 of them (24%) were subsequently eliminated from the final analysis. Therefore, 1173 patients (581 females and 592 males) were recruited. Mean age of patients was 62.0+/-18.2 years (95% confidence interval, 60.9-63.0). On the basis of Atlanta classification, 1006 patients (85.8%) were defined as mild and 167 (14.2%) as severe pancreatitis. Biliary forms represented the most frequent aetiological category (813 cases, 69.3%) while alcoholic forms only 6.6% (77 cases); the remaining aetiologies accounted for 7.1% (83 cases) while 200 cases (17.1%) remained without a definite aetiological factor. Complete recovery was achieved in 1016 patients (86.6%) whereas morphological sequelae were found in 121 patients (10.3%) and mortality in 36 patients (3.1%; 0.4% in mild and 19.2% in severe acute pancreatitis). Ultrasonography was largely utilised as a first line diagnostic tool in all patients, with valuable visualisation of the pancreas in 85% of patients. Computer tomography scan was also widely used, with 66.7% of exams in mild and 33.3% in severe pancreatitis. Patients affected by biliary pancreatitis presented more severe (p=0.004) and necrotizing forms (p=0.021). Mortality was significantly related (p<0.001) with the extension of pancreatic necrosis and with an age of over 70 years. Body mass index presented significantly greater values in severe than in mild forms (p<0.001).

CONCLUSIONS

Association of creatinine serum level over 2mg/dl with an abnormal chest X-ray showed a high significant correlation with a more severe outcome in terms of morphological sequelae and mortality (p=0.0001). Acute pancreatitis in Italy more commonly presents biliary aetiology and favourable outcome with low rate of complications and mortality. From a cost-effectiveness standpoint, diagnostic approach to this disease needs to be better standardised.

New advances in pancreatic surgery

PURPOSE OF REVIEW

New understanding of the dynamic of acute pancreatitis, the clinical impact of local pathology in chronic pancreatitis and cystic neoplastic lesions bearing high potential for malignant transformation has changed the management of pancreatic diseases.

RECENT FINDINGS

In acute pancreatitis, risk factors independently determining outcome in severe acute pancreatitis are early and persistent multiorgan failure, infected necrosis and extended sterile necrosis. The management of severe acute pancreatitis is based on early intensive-care treatment and late surgical debridement. In chronic pancreatitis, recent data from randomized controlled clinical trials have demonstrated duodenum-preserving pancreatic head resection with an inflammatory mass of the head as superior to pylorus-preserving Whipple resection. Cystic neoplasms are local lesions of the pancreas with high malignant potential. Local organ-preserving resection techniques have been applied with low morbidity and mortality, replacing a Whipple-type resection. Resection of pancreatic cancer is ineffective to cure patients. After an R0-resection, a significant survival benefit has been achieved when adjuvant chemotherapy has additionally been applied.

SUMMARY

New knowledge about the nature of inflammatory diseases, cystic neoplastic lesions and malignant pancreatic tumours has changed the indication for surgical treatment and the application of organ-preserving surgical techniques.

Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis

AIM: To determine factors related to disease severity, mortality and morbidity in acute pancreatitis.

METHODS: One hundred and ninety-nine consecutive patients were admitted with the diagnosis of acute pancreatitis (AP) in a 5-year period (1998-2002). In a prospective design, demographic data, etiology, mean hospital admission time, clinical, radiological, biochemical findings, treatment modalities, mortality and morbidity were recorded. Endocrine insufficiency was investigated with oral glucose tolerance test. The relations between these parameters, scoring systems (Ranson, Imrie and APACHE II) and patients’ outcome were determined by using invariable tests and the receiver operating characteristics curve.

RESULTS: One hundred patients were men and 99 were women; the mean age was 55 years. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). Sixty-three patients had severe pancreatitis and 136 had mild disease. Respiratory rate > 20/min, pulse rate > 90/min, increased C-reactive protein (CRP), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) levels, organ necrosis > 30% on computed tomography (CT) and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP > 142 mg/L, BUN > 22 mg/dL, LDH > 667 U/L, base excess > -5, CT severity index > 3 and APACHE score > 8 were related to morbidity and mortality.

CONCLUSION: APACHE II score, LDH, base excess and CT severity index have prognostic value and CRP is a reliable marker for predicting both mortality and morbidity.

Risk and markers of severe acute pancreatitis

Acute pancreatitis begins with pancreatic injury, elicits an acute inflammatory response, and encompasses a variety of potential complications in a subset of patients. Early determination of severity and risk of complications is crucial for instituting immediate interventions to improve outcome. The severity of acute pancreatitis is a function of the amount of pancreas that is injured and the intensity of the inflammatory response. Early death is mainly linked to an overwhelming inflammatory response leading to cardiovascular collapse or acute respiratory distress syndrome, whereas late death is associated with infected pancreatic necrosis and sepsis. This article reviews recent advancements in understanding the pathogenesis, immunology, and genetics of severe acute pancreatitis, and the literature on laboratory-based markers, which predict a severe clinical course and pancreatic necrosis.

Prevalence of primary fungal infections in necrotizing pancreatitis

BACKGROUND/AIMS

Prophylactic use of carbapenems (meropenem and imipenem) and other broad-spectrum antibiotics in necrotizing pancreatitis has been suggested as a risk factor for pancreatic fungal infections. The aim of our study was to determine the prevalence of primary fungal infections and the pattern of antibiotic use in necrotizing pancreatitis at our institution.

METHODS

Records on 689 consecutive patients with acute pancreatitis between 2000 and 2004 were reviewed. Necrotizing pancreatitis was identified by contrast-enhanced computed tomography (CT) scan. Data on antibiotic usage were collected and microbiologic data obtained from radiologic, endoscopic, and surgical interventions (pancreatic aspiration, drain placement or debridement) were reviewed for evidence of fungal infection. Pancreatic fungal infections were classified as primary if the positive culture was obtained at the time of initial intervention.

RESULTS

Among 64 patients with necrotizing pancreatitis, there were no cases of primary pancreatic fungal infections and 7 cases (11%) of secondary pancreatic fungal infections. Fifteen patients (23%) developed pancreatic bacterial infections. Among 62 patients with necrotizing pancreatitis in whom antibiotic exposure was known, 45% received carbapenems for a median duration of only 6 days, and 84% received non-carbapenem antibiotics for a median duration of 14 days.

CONCLUSION

Limited use and short duration of carbapenem therapy may be factors contributing to the absence of primary fungal infections in our study.

Elevated level of interleukin-6 predicts organ failure and severe disease in patients with acute pancreatitis

BACKGROUND AND AIM

Cytokines play an important role in the pathogenesis of acute pancreatitis (AP). The aim of the present paper was to study the profile of anti- and proinflammatory cytokines in AP and to determine their predictive value for severity of AP, organ failure and mortality.

METHODS

Consecutive patients with AP were included in the study. Cytokines were measured in those patients who presented within the first 72 h of the onset of AP. Plasma levels of proinflammatory cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-Ibeta, IL-6 and anti-inflammatory cytokine IL-10 were measured on days 1, 3, 7 and 14 of AP.

RESULTS

Of 108 patients, 30 presented within 72 h of the onset (mean age 40.27 +/- 13.89 years; 22 males). Of the 30 patients, 13 (43.3%) had severe and 17 (56.7%) had mild pancreatitis. Eleven (36.7%) patients developed organ failure and three died. The level of IL-6 on day 3 was significantly higher in severe pancreatitis than in mild pancreatitis (146.29 +/- 57.53 pg/mL vs 91.42 +/- 71.65 pg/mL; P = 0.04) and was significantly higher in patients who developed organ failure compared with those who did not (161.59 +/- 53.46 pg/mL vs 88.16 +/- 65.50 pg/mL; P = 0.004). At a cut-off value of 122 pg/mL on day 3, IL-6 predicted organ failure and severe pancreatitis with a sensitivity and specificity of 81.8% and 77.7%, respectively. TNF-alpha and IL-10 were detectable only in one-third of patients and were not related to the severity of pancreatitis, while Il-1beta was not detectable.

CONCLUSION

Elevated levels of IL-6 predicted organ failure and severe pancreatitis and suggested its pathophysiological significance in AP.

Intra-abdominal pressure in severe acute pancreatitis

BACKGROUND

Hospital mortality in patients with severe acute pancreatitis (SAP) remains high. Some of these patients develop increased intra-abdominal pressure (IAP) which may contribute to organ dysfunction. The aims of this study were to evaluate the frequency of increased IAP in patients with SAP and to assess the development of organ dysfunction and factors associated with high IAP.

METHODS

During 2001-2003 a total of 59 patients with severe acute pancreatitis were treated in the intensive care unit (ICU) of Helsinki University Hospital. IAP was measured by the intravesical route in 37 patients with SAP. Data from these patients were retrospectively reviewed.

RESULTS

Maximal IAP, APACHE II score, maximal SOFA score, maximal creatinine, age and maximal lactate were significantly higher in nonsurvivors. There was a significant correlation of the maximal IAP with the maximal SOFA, APACHE II, maximal creatinine, maximal lactate, base deficit and ICU length of stay. Patients were divided into quartiles according to the maximal IAP. Maximal IAP was 7-14, 15-18, 19-24 and 25-33 mmHg and the hospital mortality rate 10%, 12.5%, 22.2% and 50% in groups 1-4, respectively. A statistically significant difference was seen in the maximal SOFA, ICU length of stay, maximal creatinine and lactate values. The mean ICU-free days in groups 1-4 were 45.7, 38.8, 32.0 and 27.5 days, respectively. The difference between groups 1 and 4 was statistically significant.

CONCLUSION

In patients with SAP, increased IAP is associated with development of early organ failure reflected in increased mortality and fewer ICU-free days. Frequent measurement of IAP during intensive care is important in optimizing abdominal perfusion pressure and recognizing patients potentially benefitting from decompressive laparotomy.

When should we be concerned about pancreatic necrosis? Analysis from a single institution in Mexico City

BACKGROUND/AIM

Although pancreatic necrosis classifies acute pancreatitis (AP) as severe, many patients with tomographic evidence of necrosis never develop systemic complications. Our aim was to analyze the incidence of pancreatic necrosis, organ failure (OF), and the relationship between them.

METHODS

Medical records from 165 patients with a first AP episode and in whom a contrast-enhanced computed tomography (CECT) was performed were analyzed. Pancreatic necrosis was diagnosed as non-enhancing areas of the pancreas on the CECT and was graded as <30%, 30%-50%, and >50%. Pancreatic infection was assessed by guided percutaneous aspiration. Organ failure was defined according to the Atlanta criteria.

RESULTS

Of 165 patients (mean age 42 years, 85 men), 54 (33%) had pancreatic necrosis. Necrosis was graded as <30% in 25 subjects (46%), 30%-50% in 16 (30%), and >50% in 13 (24%). Pancreatic infection was diagnosed in 14 cases (26%). Organ failure occurred in 49 patients: in 20 patients (37%) with necrosis, and in 29 patients (26%) without necrosis (P = 0.20). Extensive pancreatic necrosis (>50%) (P < 0.05) and infected necrosis (P < 0.05) were significantly associated with OF. Eight patients, all of them with OF, died. In 6 of these cases infected pancreatic necrosis was present.

CONCLUSIONS

Patients with pancreatic necrosis are not necessarily at risk of developing OF. However, it should be considered an important risk factor when the necrotizing process compromises more than 50% of the gland and is infected.

Chronic alcohol consumption is a major risk factor for pancreatic necrosis in acute pancreatitis

BACKGROUND

Much of the late morbidity and mortality of acute pancreatitis (AP) is attributed to complications of pancreatic necrosis (PNEC). Early diagnosis of PNEC in high-risk patients is critical to management. Hemoconcentration is one risk factor for PNEC, but additional risk factors are likely implicated.

AIMS

(1) To evaluate a series of preselected clinical factors in a prospectively collected cohort with AP to identify risk factors for PNEC and (2) to verify the relative risk of any newly identified factor(s) by retrospective analysis of a large patient cohort.

METHODS

Phase I: 102 AP patients were prospectively ascertained, of which 77 (mean age 49 yr; 35 women, 42 men) underwent contrast-enhanced computerized tomography (CECT) and were studied. Eleven subjects developed PNEC (14%). Binary logistic regression was performed to identify any clinical factors associated with PNEC. Phase II: 1,474 anonymized patients admitted to the hospital with a diagnosis of AP were electronically reviewed to identify 359 subjects (mean age 54 yr; 157 women, 202 men) with AP and CECT. Seventy-six of these patients (21%) exhibited CECT evidence of PNEC. The associations found in the Phase I group were compared with Phase II by logistic regression analysis.

RESULTS

In Phase I, only chronic alcohol consumption was identified as a significant new risk factor for the development of PNEC (6/19 vs 5/58, p= 0.02, OR 4.8, CI 1.27-18.2). In Phase II, it was verified that excessive alcohol consumption was a significant risk factor for PNEC (18/52 vs 58/307, p= 0.012, OR 2.27, CI 1.19-4.30).

CONCLUSION

Chronic alcohol consumption seems to constitute a strong risk factor for PNEC.

Endoscopic retrograde cholangiopancreatography-induced acute pancreatitis often has a benign outcome

BACKGROUND

Acute pancreatitis (AP) is the commonest complication of endoscopic retrograde cholangiopancreatography (ERCP). Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease.

OBJECTIVE

To examine the clinical course, disease severity, and outcome of patients with post-ERCP-AP.

METHODS

All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, infectious complications, need for surgery and mortality. The clinical course and outcome of patients with post-ERCP-AP were also compared with those of patients with gallstone pancreatitis (GS-AP).

RESULTS

Of the 1497 de novo ERCP procedures, 57 (3.8%) patients developed AP. Their mean age was 40.2 years (13.1), 16 were males of them, 54 (95%) patients had mild pancreatitis. Only 2 patients developed organ failure. Fifty-four (95%) patients recovered with conservative management. One of the 57 patients died. As compared with patients with GS-AP (n=174), APACHE II scores at admission [3.3 (3.1) vs. 5.8 (4.8); P=0.011], occurrence of pancreatic necrosis (17.5% vs. 39.1%; P=0.020), organ failure (3.5% vs. 19.0%; P=0.015), infectious complications (8.7% vs. 24.7%; P=0.040), and mortality (1.8% vs. 13.2%; P=0.044) were significantly less among patients with post-ERCP-AP.

CONCLUSION

Unlike previous belief, we found that post-ERCP AP was a mild disease with a favorable outcome in most cases.

Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis

BACKGROUND

Death from infected necrosis in acute pancreatitis is common and prevention has focused on prophylactic antibiotics. This study assesses whether intravenous prophylactic antibiotic use reduces infected necrosis and death in acute necrotizing pancreatitis.

METHODS

A meta-analysis of randomized controlled trials was carried out. Medline, Web of Science, the Cochrane controlled trials register and international conference proceedings were searched, with a citation review of relevant primary and review articles.

RESULTS

Six of 328 studies assessed were included in data extraction. Primary outcome measures were infected necrosis and death. Secondary outcome measures were non-pancreatic infections, surgical intervention and length of hospital stay. Prophylactic antibiotic use was not associated with a statistically significant reduction in infected necrosis (relative risk (RR) 0.77 (95 per cent confidence interval (c.i.) 0.54 to 1.12); P = 0.173), mortality (RR 0.78 (95 per cent c.i. 0.44 to 1.39); P = 0.404), non-pancreatic infections (RR 0.71 (95 per cent c.i. 0.32 to 1.58); P = 0.402) and surgical intervention (RR 0.78 (95 per cent c.i. 0.55 to 1.11); P = 0.167). It was, however, associated with a statistically significant reduction in hospital stay (P = 0.040).

CONCLUSION

Prophylactic antibiotics do not prevent infected necrosis or death in acute necrotizing pancreatitis.

The management of suspected pancreatic sepsis

The management of infected pancreatic necrosis is centered on image-guided fine needle aspiration followed by antibiotic therapy that is based on microbiologic culture results. The authors favor targeted antibiotic therapy rather than routine prophylactic antibiotic coverage. Prompt surgical debridement is recommended for patients who have infected necrosis who are suitable operative candidates. Newer surgical, percutaneous, and endoscopic techniques, as well as prolonged antibiotic therapy without intervention, are being evaluated as alternatives to operative debridement. Well-designed prospective trials will help to determine optimal treatment for patients who have infected pancreatic necrosis.