Fatal acute pancreatitis, a clinicopathologic analysis

Deaths from acute pancreatitis: why do we miss the diagnosis so frequently?

Review of acute pancreatitis deaths between 1974 and 1984 revealed 126 patients, 53 (42%) of whom were first diagnosed at autopsy. Pancreatitis was undiagnosed in life in 13 (33%) of the patients with a gallstone aetiology, 8 (40%) of those with an alcohol aetiology, 21 (42%) of those of unknown aetiology and 17 (74%) of those with pancreatitis due to other identified aetiological factors. These patients more commonly died within the first week of their illness, more often had significant underlying medical disease and tended to have less severe degrees of pancreatic parenchymal destruction. Only 7 (13%) of the 53 patients undiagnosed in life had presented with abdominal pain. The majority (68%) presented atypically with known or suspected medical conditions, often to internists, or post-operatively (19%). Failure to diagnose these patients in life was most often due to a lack of consideration of the diagnosis, usually because of the atypical presentation, and consequent omission of an amylase determination--made in only 5 (9%) of the patients.

Prevalence of normal serum amylase levels in patients with acute alcoholic pancreatitis

Acute alcoholic pancreatitis is uncommonly diagnosed when the serum amylase level is normal. We defined acute alcoholic pancreatitis as a clinical syndrome in which hyperamylasemia was not a necessary component and sought support for the diagnosis by ultrasonography and computed tomography of the pancreas. In 68 episodes of acute alcoholic pancreatitis identified in a one-year period, the serum amylase level was normal at the time of hospital admission in 32%. In 40 episodes, we performed ultrasonography and computed tomography within 48 hr of admission. The diagnosis was supported by ultrasonography in 43%, by computed tomography in 68%. Ultrasonography and computed tomography supported the diagnosis as frequently in patients with normal serum amylase levels as in patients with hyperamylasemia. We conclude that patients with acute alcoholic pancreatitis frequently have normal serum amylase levels. The widespread clinical practice of relying solely on hyperamylasemia to establish the diagnosis of acute alcoholic pancreatitis is unjustified and should be abandoned.

Alcoholism indicators: nonreliability of events partially related to alcohol abuse

Certain events partially associated with alcohol abuse (e.g., all hepatic cirrhosis) as well as those wholly associated with alcohol abuse (e.g., alcoholic cirrhosis) have been used to assess changes in alcoholism rates over time. In this paper, events partially associated with alcohol abuse are compared with events wholly correlated with alcohol abuse. Location and time of the study was the state of Minnesota from 1965 to 1977. Taken as a whole, the partially related events fail to show an increase in alcoholism while the wholly related events point to an increase. The literature on these alcohol-related events is reviewed, and theories for the discrepancies between partially and wholly related events are offered.

Diagnostic peritoneal lavage in acute pancreatitis--the value of microscopy of the lavage fluid

In only 2 of 98 cases with a clinical diagnosis of acute pancreatitis submitted to peritoneal lavage in order to assess severity was the diagnosis found to be wrong. These two cases (one was biliary peritonitis and the other mesenteric infarction) were not differentiated from severe pancreatitis by clinical examination, measurement of plasma amylase, the appearance of the lavage fluid or its amylase or white cell count. One case was exceptional in that the lavage fluid had a faecal odour, and both cases were found to have large numbers of intestinal organisms which were clearly visible on routine microscopy. Scanty commensals (? contaminants) were seen in the lavage fluid of 2 of the 96 patients with acute pancreatitis but no intestinal organisms were found. If peritoneal lavage is used in the management of acute pancreatitis, microscopy of the lavage fluid, carried out as an emergency investigation, might help to detect the occasional case with a false diagnosis.

The ultrasonic and biochemical diagnosis of pancreatitis in children

Pancreatic ultrasonography and the determination of serum amylase and amylase creatinine clearance ration were performed on 17 normal children and on 35 children with abdominal pain. In all 17 normal subjects the echodensity of the pancreas was equal to or greater than that of the liver. Nineteen patients with abdominal pain had reduced echodensity of the pancreas when compared to that in normal children, and two of the 19 had pseudocysts. Serum amylase values and/or amylase creatinine clearance ratio correlated poorly with ultrasonic and clinical evidence of pancreatitis.

The role of peritoneal lavage in severe acute pancreatitis

Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with "severe" pancreatitis. One hundred and three patients with "severe" pancreatitis (28% mortality) were separated from 347 with "mild" pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0-7) of "severe" pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with "severe" pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48-96 hours, usually using 36-48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment of pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Group B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was no affected (Group A, 83%; B, 84%; C, 33%; D,33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.

Validity of the correlation of gallstones and pancreatic pathology

In a necropsy survey of 724 patients from the Hebrew University Hospital (1964-67) 107 patients were found with gallstones. Ninety-five patients matched according to age and sex served as controls. No difference was found between control and gallstone patients with regard to the incidence and type of pancreatic pathology, except for intestinal metaplasia which was more frequent in the controls. Significantly more pancreatic pathology was found in Ashkenazi-born patients without gallstones than in the respective non-Ashkenazi group. In patients with gallstones no difference in pancreatic pathology was found between the two ethnic groups.Females with gallstones had significantly more hepatic disease than females without gallstones. This difference was not found in males. Hepatic disease alone was associated with a higher incidence of pancreatic pathology.