Accuracy of early CT findings for predicting disease course in patients with acute pancreatitis

Early detection of necrosis in low-enhanced pancreatic parenchyma using contrast-enhanced computed tomography was a better predictor of clinical outcomes than pancreatic inflammation: A multicentric cohort study of severe acute pancreatitis

OBJECTIVES

We aim to assess the early use of contrast-enhanced computed tomography (CECT) of patients with severe acute pancreatitis (SAP) using the computed tomography severity index (CTSI) in prognosis prediction. The CTSI combines quantification of pancreatic and extrapancreatic inflammation with the extent of pancreatic necrosis.

METHODS

Post-hoc retrospective analysis of a large, multicentric database (44 institutions) of SAP patients in Japan. The area under the curve (AUC) of the CTSI for predicting mortality and the odds ratio (OR) of the extent of pancreatic inflammation and necrosis were calculated using multivariable analysis.

RESULTS

In total, 1097 patients were included. The AUC of the CTSI for mortality was 0.65 (95 % confidence interval [CI:] [0.59-0.70]; p < 0.001). In multivariable analysis, necrosis 30-50 % and >50 % in low-enhanced pancreatic parenchyma (LEPP) was independently associated with a significant increase in mortality, with OR 2.04 and 95 % CI 1.01-4.12 (P < 0.05) and OR 3.88 and 95 % CI 2.04-7.40 (P < 0.001), respectively. However, the extent of pancreatic inflammation was not associated with mortality, regardless of severity.

CONCLUSIONS

The degree of necrosis in LEPP assessed using early CECT of SAP was a better predictor of mortality than the extent of pancreatic inflammation.

Correlation between Balthazar CT grading, CECT necrosis volume, attenuation value, and prognosis of patients with acute necrotizing pancreatitis

To analyze the correlation between Balthazar CT grading and contrast-enhanced CT necrosis volume and attenuation value and prognosis of patients with acute necrotizing pancreatitis. Ninety-two patients with acute necrotizing pancreatitis who were treated in the hospital were selected between June 2019 and June 2021, and they were divided into the poor prognosis group and the good prognosis group according to the clinical prognosis at 6 months of follow-up. Balthazar CT, contrast-enhanced CT necrosis volume, and attenuation value were compared between the 2 groups. Multivariate logistic regression analysis was used to analyze the influencing factors. Receiver operating characteristic curve was adopted to analyze the predictive value. Among the 92 participants, there were 28 cases with good prognosis (30.43%) and 64 cases with poor prognosis (69.57%). The Acute Physiology and Chronic Health Evaluation II score, C-reactive protein, urea nitrogen, Balthazar CT, necrotic volume, and average attenuation value of the poor prognosis group were significantly higher than those of the good prognosis group (all P values <.05). The results of the multivariate logistic analysis showed that Balthazar CT grade, necrotic volume, and average attenuation value were independent risk factors for poor prognosis in patients with acute necrotizing pancreatitis (all P values <.05). The area under the curve of Balthazar CT grade, necrotic volume, average attenuation value, and the joint detection in predicting the prognosis of patients with acute necrotizing pancreatitis were 0.765, 0.624, 0.764, and 0.861, respectively. The Balthazar CT grading, necrosis volume, and average attenuation value are significantly higher among patients with acute necrotizing pancreatitis complicated with poor prognosis, and they are also independent risk factors for poor prognosis in patients with acute necrotizing pancreatitis, and can help clinically predict the prognosis of patients with acute necrotizing pancreatitis, and the combined detection has better application effects.

Prediction of acute pancreatitis complications using routine blood parameters during early admission

BACKGROUND

There have been many reports on biomarkers for predicting the severity of acute pancreatitis (AP), but few studies on biomarkers for predicting complications; some simple and inexpensive indicators, in particular, are worth exploring.

METHODS

We retrospectively collected clinical data of 809 AP patients, including medical history and results of routine blood tests, and grouped them according to the occurrence of complications. Differences in clinical characteristics between groups with and without complications were compared using t-test or χ² test. Receiver operating curve (ROC) and area under the curve were calculated to evaluate the ability of predicting the occurrence of complications for the routine blood parameters with statistical differences. Then, through univariate and multivariate analyses, independent risk factors closely associated with complications were identified. Finally, we built a three-parameter prediction system and evaluated its ability to predict AP complications.

RESULTS

Compared with the group without complications, the patients in the complication group had higher white blood cells, neutrophils, C-reactive protein, and erythrocyte sedimentation rate (ESR), and lower red blood cells and hemoglobin (Hb) (all p < .05), and most of them had severe pancreatitis. In addition, pseudocysts were more common in patients with alcoholic etiology, recurrence, low BMI, and high platelet (PLT) and plateletocrit. Acute respiratory failure was more common in patients with first onset and high mean PLT volume (MPV). Sepsis was more common in patients with lipogenic etiology, high MPV, and low lymphocytes. Infectious pancreatic necrosis was more common in patients with alcoholic etiology. Acute renal failure was more common in patients with monocytes and high MPV and low PLT. Multivariate analysis showed that PLT and ESR were risk factors for pseudocyst development. The ROC showed that the combination of Hb, PLT and ESR had a significantly higher predictive ability for pseudocyst than the single parameter.

CONCLUSION

Routine blood parameters can be used to predict the complications of AP. A predictive model combining ESR, PLT, and Hb may be an effective tool for identifying pseudocysts in AP patients.

EASY-APP: An artificial intelligence model and application for early and easy prediction of severity in acute pancreatitis

Background

Acute pancreatitis (AP) is a potentially severe or even fatal inflammation of the pancreas. Early identification of patients at high risk for developing a severe course of the disease is crucial for preventing organ failure and death. Most of the former predictive scores require many parameters or at least 24 h to predict the severity; therefore, the early therapeutic window is often missed.

Methods

The early achievable severity index (EASY) is a multicentre, multinational, prospective and observational study (ISRCTN10525246). The predictions were made using machine learning models. We used the scikit‐learn, xgboost and catboost Python packages for modelling. We evaluated our models using fourfold cross‐validation, and the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), and accuracy metrics were calculated on the union of the test sets of the cross‐validation. The most critical factors and their contribution to the prediction were identified using a modern tool of explainable artificial intelligence called SHapley Additive exPlanations (SHAP).

Results

The prediction model was based on an international cohort of 1184 patients and a validation cohort of 3543 patients. The best performing model was an XGBoost classifier with an average AUC score of 0.81 ± 0.033 and an accuracy of 89.1%, and the model improved with experience. The six most influential features were the respiratory rate, body temperature, abdominal muscular reflex, gender, age and glucose level. Using the XGBoost machine learning algorithm for prediction, the SHAP values for the explanation and the bootstrapping method to estimate confidence, we developed a free and easy‐to‐use web application in the Streamlit Python‐based framework (http://easy‐app.org/).

Conclusions

The EASY prediction score is a practical tool for identifying patients at high risk for severe AP within hours of hospital admission. The web application is available for clinicians and contributes to the improvement of the model.

Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study

Background and Objectives: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. Materials and Methods: A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (<30%, 30−50%, >50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. Results: The study included 83 patients (75.9% males (n = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients (n = 42, 51%). Positive blood culture (n = 14 (87.5%)), multiple organ dysfunction syndrome (n = 17 (73.9%)) and incidences of respiratory failure (n = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% (p < 0.05). Patients with >50% of necrosis were significantly (p < 0.05) more often diagnosed with moderately severe (n = 24 (41.4%)) and severe (n = 18 (72%)) AP. The number of surgical interventions (n = 18 (72%)) and ultrasound-guided interventions (n = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency (n = 11 (64.7%)) and infected pancreatic necrosis (n = 19 (57.6%)) was significantly higher (p < 0.05). Conclusions: The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.

The course of acute pancreatitis in patients with different BMI groups

OBJECTIVES

To evaluate the risk factors, Atlanta severity score, Balthazar-CTSI score, and disease course in patients of varying weight with acute pancreatitis (AP).

METHODS

A retrospective evaluation was made of normal weight (NW), overweight (OW), and obese (OB) patients (n:1134) with respect to demographic findings, diabetes (DM)/hypertension, smoking/alcohol use, etiologies, laboratory findings, Balthazar/Atlanta severity scores, and disease outcomes. After consistency and associations among the BMI, Balthazar, and Atlanta groups were evaluated, combined effects of risk factors on mortality, hospital and ICU stays were re-examined statistically.

RESULTS

In the OB group, mean age (p < 0.001), female gender (p < 0.001), increased BUN(p < 0.027) and Hct (p = 0.039), DM(p < 0.024), and mortality (p < 0.011) were statistically significant. In the non-NW groups, the rates of complications (40.6%/38.6%), mortality (3.7%/4.9%), interventional procedures (36%/39%), and length of hospital stay (11.6%/9.8%) were increased. Obesity constituted 23.7% of severe AP(SAP) and 50% of mortality. There was no significant relationship between Atlanta and Balthazar groups and BMI, nor between Balthazar and moderate AP (MSAP) to SAP. Old age (p = 0.000), male sex (p = 0.05), obesity (p = 0.046), alcohol (p = 0.014), low Hct (p = 0.044), high CRP (p = 0.024), MSAP/SAP (p = 0.02/(p < 0.001), and any complications (p < 0.001) increased the mortality risk. Female gender (p = 0.024), smoking (p = 0.021), hypertriglyceridemia (p = 0.047), idiopathic etiology (p = 0.023), and MSAP/SAP (p < 0.001) associations increased ICU admission. Co-occurrences of higher Balthazar score (p < 0.001), MSAP/SAP (p < 0.001), all kinds of complications (p < 0.001), and recurrence (p = 0.040) increased the hospital stay (≥11 days).

CONCLUSIONS

Although complications, mortality, longer hospitalization, and interventional procedures were observed more in the overweight and obese, successful prediction of Atlanta severity and Balthazar-CTSI scores based on BMI does not appear to be accurate. OB carries an increased risk for morbidity and mortality. The combined effects of risk factors increased mortality, longer hospital stays, and ICU admission.

The prognostic value of fat necrosis deposits on CT imaging in acute pancreatitis

Background/aim

Investigate the prognostic value of the fat necrosis deposit (FND) pattern in acute pancreatitis.

Materials and methods

The contrast-enhanced computed tomography (CT) images of 35 necrotizing pancreatitis (NP) and 51 edematous pancreatitis (EP) cases were included in our retrospective study. Computed tomography severity index (CTSI) and Ranson scores were calculated. Images were evaluated for FND, complications (infection/ hemorrhage), walled-off necrosis (WON), and venous thrombosis (VT). We developed a new grading system called fat necrosis deposit-CTSI (FND-CTSI), which was the sum of FND and CTSI scores. The relationship between grading systems and mortality, length of hospital-intensive care unit stay, surgical and percutaneous interventions were evaluated.

Results

FND-CTSI scores were significantly higher in NP than EP (P < 0.001). FND-CTSI demonstrated a significant correlation with CTSI (r:0.91, P < 0.001) and Ranson score (r:0.24, P = 0.025). CTSI was significantly higher in only mass form amongst the FND groups (P < 0.001). There was a significant difference in WON, complications, and mortality between FND groups (P < 0.05). CTSI and FND-CTSI scores were both significantly associated with WON, VT, surgical intervention, mortality (P < 0.001), and the presence of complications (P = 0.013 and P = 0.007, respectively). FND-CTSI was also significantly associated with percutaneous intervention (P = 0.019), while CTSI was not (P > 0.05). According to ROC analysis, AUC values of FND-CTSI were higher than CTSI for the detection of WON, complications, mortality, and percutaneous intervention (P < 0.05). FND-CTSI showed a highly significant correlation with the length of hospital and intensive care unit stays (P < 0.001).

Conclusion

FND-CTSI can be used in acute pancreatitis grading and considered as a prognostic factor.

Acute Pancreatitis: A Review

IMPORTANCE

In the United States, acute pancreatitis is one of the leading causes of hospital admission from gastrointestinal diseases, with approximately 300 000 emergency department visits each year. Outcomes from acute pancreatitis are influenced by risk stratification, fluid and nutritional management, and follow-up care and risk-reduction strategies, which are the subject of this review.

OBSERVATIONS

MEDLINE was searched via PubMed as was the Cochrane databases for English-language studies published between January 2009 and August 2020 for current recommendations for predictive scoring tools, fluid management and nutrition, and follow-up and risk-reduction strategies for acute pancreatitis. Several scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity (mild, moderately severe, and severe per the revised Atlanta classification) and mortality, but no one tool works well for all forms of acute pancreatitis. Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications, yet the optimal type and rate of fluid resuscitation have yet to be determined. The underlying etiology of acute pancreatitis should be sought in all patients, and risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis.

CONCLUSIONS AND RELEVANCE

Acute pancreatitis is a complex disease that varies in severity and course. Prompt diagnosis and stratification of severity influence proper management. Scoring systems are useful adjuncts but should not supersede clinical judgment. Fluid management and nutrition are very important aspects of care for acute pancreatitis.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca²⁺) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.

Utility of the portal venous phase for diagnosing pancreatic necrosis in acute pancreatitis using the CT severity index

PURPOSE

The purpose of the study was to evaluate the value of portal venous phase (PVP) images in the diagnosis of pancreatic necrosis in patients with acute pancreatitis using computed tomography severity index (CTSI).

METHODS

This retrospective study was approved by our Institutional Review Board, and written informed consent was waived. Dynamic contrast-enhanced CT images, with the pancreatic parenchymal phase (PPP) and the PVP, were obtained from 56 consecutive patients with acute pancreatitis. Two radiologists reviewed two sets of images, namely PPP images alone (image set A) and combined PPP and PVP images (image set B) to evaluate the CTSI. Cases were categorized as necrotizing pancreatitis if ensuing walled-off necrosis formation was identified 4 weeks after onset of symptoms. The relationship between pancreatic necrosis and CTSI was compared between image sets A and B. Logistic regression analysis was performed to evaluate the significance of clinical and radiological factors associated with the diagnosis of pancreatic necrosis.

RESULTS

Pancreatic necrosis was confirmed in 14 out of 56 (25%) patients. The area under the receiver-operating-characteristic curve (AUC) for the diagnosis of pancreatic necrosis was 0.70 and 0.78 for image sets A and B, respectively. The AUC for image set B was significantly greater than that for image set A (P = 0.0002). Logistic regression analysis demonstrated that among clinical and radiological factors tested, CTSI for image set B was independently correlated with pancreatic necrosis (P = 0.025).

CONCLUSIONS

Combined PPP and PVP images significantly improved the diagnostic accuracy of pancreatic necrosis following acute pancreatitis.