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Metri A, Bush N, Singh VK. Predicting the severity of acute pancreatitis: Current approaches and future directions. Surg Open Sci 2024; 19:109-117. [PMID: 38650599 PMCID: PMC11033200 DOI: 10.1016/j.sopen.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Acute pancreatitis (AP) is a sudden-onset inflammatory disease of the pancreas. The severity of AP is classified into mild, moderate, and severe categories based on the presence and persistence of organ failure. Severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. It requires early recognition for appropriate timely management. Prognostic scores for predicting SAP incorporating many clinical, laboratory, and radiological parameters have been developed in the past. However, all of these prognostic scores have low positive predictive value for SAP and some of these scores require >24 h for assessment. There is a need to develop biomarkers that can accurately identify patients at risk for SAP early in the course of the presentation. In this review, we aim to provide a summary of the most commonly utilized prognostic scores for AP and discuss future directions.
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Affiliation(s)
- Aida Metri
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nikhil Bush
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Vikesh K. Singh
- Department of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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2
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Ammer-Herrmenau C, Antweiler KL, Asendorf T, Beyer G, Buchholz SM, Cameron S, Capurso G, Damm M, Dang L, Frost F, Gomes A, Hamm J, Henker R, Hoffmeister A, Meinhardt C, Nawacki L, Nunes V, Panyko A, Pardo C, Phillip V, Pukitis A, Rasch S, Riekstina D, Rinja E, Ruiz-Rebollo ML, Sirtl S, Weingarten M, Sandru V, Woitalla J, Ellenrieder V, Neesse A. Gut microbiota predicts severity and reveals novel metabolic signatures in acute pancreatitis. Gut 2024; 73:485-495. [PMID: 38129103 PMCID: PMC10894816 DOI: 10.1136/gutjnl-2023-330987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/03/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Early disease prediction is challenging in acute pancreatitis (AP). Here, we prospectively investigate whether the microbiome predicts severity of AP (Pancreatitis-Microbiome As Predictor of Severity; P-MAPS) early at hospital admission. DESIGN Buccal and rectal microbial swabs were collected from 424 patients with AP within 72 hours of hospital admission in 15 European centres. All samples were sequenced by full-length 16S rRNA and metagenomic sequencing using Oxford Nanopore Technologies. Primary endpoint was the association of the orointestinal microbiome with the revised Atlanta classification (RAC). Secondary endpoints were mortality, length of hospital stay and severity (organ failure >48 hours and/or occurrence of pancreatic collections requiring intervention) as post hoc analysis. Multivariate analysis was conducted from normalised microbial and corresponding clinical data to build classifiers for predicting severity. For functional profiling, gene set enrichment analysis (GSEA) was performed and normalised enrichment scores calculated. RESULTS After data processing, 411 buccal and 391 rectal samples were analysed. The intestinal microbiome significantly differed for the RAC (Bray-Curtis, p value=0.009), mortality (Bray-Curtis, p value 0.006), length of hospital stay (Bray-Curtis, p=0.009) and severity (Bray-Curtis, p value=0.008). A classifier for severity with 16 different species and systemic inflammatory response syndrome achieved an area under the receiving operating characteristic (AUROC) of 85%, a positive predictive value of 67% and a negative predictive value of 94% outperforming established severity scores. GSEA revealed functional pathway units suggesting elevated short-chain fatty acid (SCFA) production in severe AP. CONCLUSIONS The orointestinal microbiome predicts clinical hallmark features of AP, and SCFAs may be used for future diagnostic and therapeutic concepts. TRIAL REGISTRATION NUMBER NCT04777812.
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Affiliation(s)
- Christoph Ammer-Herrmenau
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Kai L Antweiler
- Department of Medical Statistics, University Medical Centre Goettingen, Goettingen, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre Goettingen, Goettingen, Germany
| | - Georg Beyer
- Department of Medicine II, Ludwig Maximilians University Hospital, Munich, Germany
| | - Soeren M Buchholz
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Silke Cameron
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Marko Damm
- Internal Medicine I, University Hospital Halle, Halle, Germany
| | - Linh Dang
- Department Medical Bioinformatics, University Medical Centre Goettingen, Goettingen, Germany
| | - Fabian Frost
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Antonio Gomes
- Department of General Surgery, Hospital Professor Doctor Fernando Fonseca, Amadora, Amadora, Portugal
| | - Jacob Hamm
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Robert Henker
- Medical Department II, Division of Gastroenterology, University Hospital Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Medical Department II, Division of Gastroenterology, University Hospital Leipzig, Leipzig, Germany
| | - Christian Meinhardt
- University Clinic of Internal Medicine - Gastroenterology, University Hospital Oldenburg, Oldenburg, Germany
| | - Lukasz Nawacki
- Collegium Medicum, The Jan Kochanowski University in Kielce, Kielce, Poland
| | - Vitor Nunes
- Department of General Surgery, Hospital Professor Doctor Fernando Fonseca, Amadora, Amadora, Portugal
| | - Arpad Panyko
- 4th Department of Surgery, University Hospital Bratislava, Bratislava, Slovakia
| | - Cesareo Pardo
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Veit Phillip
- Department of Internal Medicine II, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Aldis Pukitis
- Center of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Sebastian Rasch
- Department of Internal Medicine II, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Diana Riekstina
- Center of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Ecaterina Rinja
- Clinical Emergency Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Simon Sirtl
- Department of Medicine II, Ludwig Maximilians University Hospital, Munich, Germany
| | - Mark Weingarten
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Vasile Sandru
- Clinical Emergency Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Julia Woitalla
- Department of Medicine II, University Hospital of Rostock, Rostock, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
| | - Albrecht Neesse
- Department of Gastroenterology, gastrointestinal Oncology and Endocrinology, University Medical Centre Goettingen, Goettingen, Germany
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3
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Zhang J, Du JJ, Ji YF, Zhang XY, Su T, Jiang R, Fu QS, Yang GQ, Yang GD, Zhang XM. CT Features of Recurrent Acute Pancreatitis: Early Phase Versus Late Phase. J Comput Assist Tomogr 2023; 47:856-863. [PMID: 37948359 DOI: 10.1097/rct.0000000000001498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the computed tomography (CT) features of recurrent acute pancreatitis (RAP) in the early phase and late phase. METHODS Recurrent acute pancreatitis data were obtained over the past 5 years. Recurrent acute pancreatitis patients were divided into 2 groups according to the time from RAP onset to performing CT examination: the early phase (first week) and late phase (after the first week) based on the 2012 revised Atlanta classification (RAC). Evaluation and comparison of patients' demographic data, RAC, CT findings, CT severity index (CTSI) score, and extrapancreatic inflammation on CT (EPIC) score were conducted in the 2 groups. RESULTS Hypertriglyceridemia was the most common cause of RAP in 679 of 686 patients (positive CT rate: 98.98%). Among 679 CT-positive patients, interstitial edematous pancreatitis and necrotizing pancreatitis accounted for 61.71% (419/679) and 38.29% (260/679), respectively. The CTSI and EPIC scores were higher in the late phase than in the early phase (both P 's < 0.05). The proportion of moderately severe and severe RAP patients based on RAC was higher in the late phase than in the early phase ( P < 0.05). Early-stage EPIC score was more accurate than CTSI and Acute Physiology and Chronic Health Evaluation (APACHE) II scores in predicting clinically severe RAP (EPIC vs CTSI; EPIC vs APACHE II, both P 's < 0.05). CONCLUSIONS Recurrent acute pancreatitis is more severe in the late phase than in the early phase. The EPIC score is more indicative of clinically severe RAP than CTSI and APACHE II scores in the early phase of RAP.
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Affiliation(s)
| | - Juan Juan Du
- From the Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong
| | - Yi Fan Ji
- From the Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong
| | - Xin Yu Zhang
- From the Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong
| | - Ting Su
- From the Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong
| | - Rui Jiang
- Department of Radiology, People's Liberation Army The General Hospital of Western Theater Command, Chengdu
| | - Quan Shui Fu
- Department of Radiology, Suining Central Hospital, Suining
| | - Guo Qing Yang
- Department of Radiology, Suining Central Hospital, Suining
| | - Guo Dong Yang
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xiao Ming Zhang
- From the Medical Imaging Key Laboratory of Sichuan Province and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong
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4
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Liu Y, Liu H, Rong Y, Shi Q, Yang Q, Li H, Zhang Z, Tao J. Alterations of oral microbiota are associated with the development and severity of acute pancreatitis. J Oral Microbiol 2023; 15:2264619. [PMID: 37808891 PMCID: PMC10557549 DOI: 10.1080/20002297.2023.2264619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
Acute pancreatitis (AP) is a common abdomen clinical emergency. Most APs have mild clinical symptoms and a good prognosis. However, about 20% of patients develop severe acute pancreatitis (SAP), increasing morbidity and mortality. The microbiome's impact on AP pathophysiology has received increasing attention. Hence, to explore changes in oral microbial composition in acute pancreatitis, we collected clinical information and oral saliva samples from 136 adult participants: 47 healthy controls, 43 acute mild AP (MAP), 29 moderate AP (MSAP), and 17 severe AP (SAP). Using 16S rRNA gene sequencing, 663,175 high-quality sequences were identified. The relative abundance and diversity of oral microorganisms in AP patients increased, with decreased beneficial bacteria such as Streptococcus, Neisseria, and Gemella, and increased Prevotella, Veillonella, Granulicatella, Actinomyces, and Peptostreptococcus in the AP group. Further changes in microbial composition occurred with increasing disease severity, including a decreased abundance of beneficial bacteria such as Neisseria, Haemophilus, and Gemella in MSAP and SAP compared to MAP. Moreover, the Lefse analysis showed that Prevotella, Peptostreptococcus, Actinomyces, and Porphyromonas were better microbial markers for AP. Therefore, oral microbiome changes could distinguish AP from healthy individuals and serve as an early novel predictor of disease severity in AP patients.
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Affiliation(s)
- Yiting Liu
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hang Liu
- Department of Clinical Laboratory, Institute of Translational Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuping Rong
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiao Shi
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qiang Yang
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hanjun Li
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhengle Zhang
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jing Tao
- Department of Pancreatic Surgery, Renmin Hospital of Wuhan University, Wuhan, China
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5
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Kiss S, Pintér J, Molontay R, Nagy M, Farkas N, Sipos Z, Fehérvári P, Pecze L, Földi M, Vincze Á, Takács T, Czakó L, Izbéki F, Halász A, Boros E, Hamvas J, Varga M, Mickevicius A, Faluhelyi N, Farkas O, Váncsa S, Nagy R, Bunduc S, Hegyi PJ, Márta K, Borka K, Doros A, Hosszúfalusi N, Zubek L, Erőss B, Molnár Z, Párniczky A, Hegyi P, Szentesi A. Early prediction of acute necrotizing pancreatitis by artificial intelligence: a prospective cohort-analysis of 2387 cases. Sci Rep 2022; 12:7827. [PMID: 35552440 PMCID: PMC9098474 DOI: 10.1038/s41598-022-11517-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/07/2022] [Indexed: 12/21/2022] Open
Abstract
Pancreatic necrosis is a consistent prognostic factor in acute pancreatitis (AP). However, the clinical scores currently in use are either too complicated or require data that are unavailable on admission or lack sufficient predictive value. We therefore aimed to develop a tool to aid in necrosis prediction. The XGBoost machine learning algorithm processed data from 2387 patients with AP. The confidence of the model was estimated by a bootstrapping method and interpreted via the 10th and the 90th percentiles of the prediction scores. Shapley Additive exPlanations (SHAP) values were calculated to quantify the contribution of each variable provided. Finally, the model was implemented as an online application using the Streamlit Python-based framework. The XGBoost classifier provided an AUC value of 0.757. Glucose, C-reactive protein, alkaline phosphatase, gender and total white blood cell count have the most impact on prediction based on the SHAP values. The relationship between the size of the training dataset and model performance shows that prediction performance can be improved. This study combines necrosis prediction and artificial intelligence. The predictive potential of this model is comparable to the current clinical scoring systems and has several advantages over them.
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Affiliation(s)
- Szabolcs Kiss
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, 6720, Hungary.,Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Heim Pál National Pediatric Institute, Üllői út 86, Budapest, 1089, Hungary
| | - József Pintér
- Human and Social Data Science Lab, Budapest University of Technology and Economics, Műegyetem rkp. 3, Budapest, 1111, Hungary
| | - Roland Molontay
- Human and Social Data Science Lab, Budapest University of Technology and Economics, Műegyetem rkp. 3, Budapest, 1111, Hungary.,Stochastics Research Group, Hungarian Academy of Sciences, Budapest University of Technology and Economics, Egry József u. 1, Budapest, 1111, Hungary
| | - Marcell Nagy
- Human and Social Data Science Lab, Budapest University of Technology and Economics, Műegyetem rkp. 3, Budapest, 1111, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Institute of Bioanalysis, Medical School, University of Pécs, Honvéd u. 1, Pécs, 7624, Hungary
| | - Zoltán Sipos
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary
| | - Péter Fehérvári
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Department of Biomathematics and Informatics, University of Veterinary Medicine, István u. 2, Budapest, 1078, Hungary
| | - László Pecze
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary
| | - Mária Földi
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, 6720, Hungary.,Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Heim Pál National Pediatric Institute, Üllői út 86, Budapest, 1089, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Ifjúság út 13, Pécs, 7624, Hungary
| | - Tamás Takács
- Department of Medicine, University of Szeged, Kálvária sgt. 57, Szeged, 6725, Hungary
| | - László Czakó
- Department of Medicine, University of Szeged, Kálvária sgt. 57, Szeged, 6725, Hungary
| | - Ferenc Izbéki
- Department of Internal Medicine, Szent György Teaching Hospital of County Fejér, Seregélyesi út 3, Székesfehérvár, 8000, Hungary
| | - Adrienn Halász
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, 6720, Hungary.,Department of Internal Medicine, Szent György Teaching Hospital of County Fejér, Seregélyesi út 3, Székesfehérvár, 8000, Hungary
| | - Eszter Boros
- Department of Internal Medicine, Szent György Teaching Hospital of County Fejér, Seregélyesi út 3, Székesfehérvár, 8000, Hungary
| | - József Hamvas
- Bajcsy-Zsilinszky Hospital, Maglódi út 89-91, Budapest, 1106, Hungary
| | - Márta Varga
- Department of Gastroenterology, BMKK Dr Rethy Pal Hospital, Gyulai út 18, Békéscsaba, 5600, Hungary
| | - Artautas Mickevicius
- Vilnius University Hospital Santaros Clinics, Clinics of Abdominal Surgery, Nephrourology and Gastroenterology, Faculty of Medicine, Vilnius University, Santariškių g. 2, 08410, Vilnius, Lithuania
| | - Nándor Faluhelyi
- Department of Medical Imaging, Medical School, University of Pécs, Ifjúság út 13, Pécs, 7624, Hungary
| | - Orsolya Farkas
- Department of Medical Imaging, Medical School, University of Pécs, Ifjúság út 13, Pécs, 7624, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Rita Nagy
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Heim Pál National Pediatric Institute, Üllői út 86, Budapest, 1089, Hungary.,Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Stefania Bunduc
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Doctoral School, Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, 050474, Bucharest, Romania
| | - Péter Jenő Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross u. 23, Budapest, 1082, Hungary
| | - Katalin Márta
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross u. 23, Budapest, 1082, Hungary
| | - Katalin Borka
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,2nd Department of Pathology, Semmelweis University, Üllői út 93, Budapest, 1091, Hungary
| | - Attila Doros
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Baross u. 23, Budapest, 1082, Hungary
| | - Nóra Hosszúfalusi
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Department of Internal Medicine and Hematology, Semmelweis University, Szentkirályi u. 46, Budapest, 1088, Hungary
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, 1082, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross u. 23, Budapest, 1082, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, 1082, Hungary.,Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, ul. św. Marii Magdaleny 14, 61861, Poznan, Wielkopolska, Poland
| | - Andrea Párniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Heim Pál National Pediatric Institute, Üllői út 86, Budapest, 1089, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.,Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.,Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross u. 23, Budapest, 1082, Hungary
| | - Andrea Szentesi
- Doctoral School of Clinical Medicine, Faculty of Medicine, University of Szeged, Szeged, 6720, Hungary. .,Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Szigeti út 12., II. Emelet, Pécs, 7624, Hungary.
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6
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Ammer-Herrmenau C, Asendorf T, Beyer G, Buchholz SM, Cameron S, Damm M, Frost F, Henker R, Jaster R, Phillip V, Placzek M, Ratei C, Sirtl S, van den Berg T, Weingarten MJ, Woitalla J, Mayerle J, Ellenrieder V, Neesse A. Study protocol P-MAPS: microbiome as predictor of severity in acute pancreatitis-a prospective multicentre translational study. BMC Gastroenterol 2021; 21:304. [PMID: 34332533 PMCID: PMC8325304 DOI: 10.1186/s12876-021-01885-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022] Open
Abstract
Background Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients.
Methods We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality. Discussion If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future. Trial registration: ClinicalTrials.gov Identifier: NCT04777812
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Affiliation(s)
- C Ammer-Herrmenau
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - T Asendorf
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - G Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - S M Buchholz
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - S Cameron
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - M Damm
- Department of Medicine I, University Hospital Halle, Halle, Germany
| | - F Frost
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - R Henker
- Division of Gastroenterology, Medical Department II, University Hospital of Leipzig, Leipzig, Germany
| | - R Jaster
- Department of Medicine II, University Hospital Rostock, Rostock, Germany
| | - V Phillip
- Department of Medicine II, University Hospital rechts der Isar, Technical University Munich, Munich, Germany
| | - M Placzek
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - C Ratei
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - S Sirtl
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - T van den Berg
- Department of Medical Bioinformatics, University Medical Center, Göttingen, Germany
| | - M J Weingarten
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - J Woitalla
- Department of Medicine II, University Hospital Rostock, Rostock, Germany
| | - J Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - V Ellenrieder
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany
| | - A Neesse
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center, Robert-Kochsstraße 40, 37075, Göttingen, Germany.
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7
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Huber W, Schneider J, Schmid RM. Therapie der schweren akuten Pankreatitis. DER GASTROENTEROLOGE 2020. [DOI: 10.1007/s11377-020-00422-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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8
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Abstract
Acute pancreatitis (AP) has an annual incidence of 30-45 per 100,000 inhabitants. In Germany approximately one third of the cases are of biliary or alcoholic origin. The diagnosis is based on the typical epigastric pain with radiation and a threefold increase of lipase or amylase in serum. Imaging procedures only rarely need to be included for the primary diagnostics. An early risk assessment is important to be able to allocate patients with severe AP to surveillance in an intensive care unit (ICU). Elevation of blood urea nitrogen, hematocrit and blood glucose are early predictors of poor outcome.The removal of impacted gall-stones by endoscopic retrograde cholangiography (ERC) is the only causal treatment of biliary AP, which must be carried out when there are signs of cholangitis and in severe biliary AP. Pain management and early fluid substitution are the most important symptomatic approaches. In the early phase of AP 150-250 ml/h of crystalloid solution should be administered to compensate for the extravasal loss of fluid. In certain cases, the initial fluid requirement might be even higher. In the ICU setting echocardiography and advanced hemodynamic monitoring are available for guidance. Prophylactic antibiotic treatment is not recommended in mild AP and it is a matter of debate even in severe AP. Early enteral nutrition has been shown to improve the outcome. Even in cases of fluid collection and necrosis a primary surgery approach should be avoided in favor of a "step-up" procedure with radiologically guided drainage as well as endoscopic and if necessary video-assisted percutaneous retroperitoneal débridement. Surgery remains an option for complications and for infected necrosis which cannot be reached by any other means.
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Affiliation(s)
- Wolfgang Huber
- Medizinische Klinik und Poliklinik II, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Hana Algül
- Medizinische Klinik und Poliklinik II, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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Kamal A, Faghih M, Moran RA, Afghani E, Sinha A, Parsa N, Makary MA, Zaheer A, Fishman EK, Khashab MA, Kalloo AN, Singh VK. Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis. Scand J Gastroenterol 2018; 53:88-93. [PMID: 29017354 DOI: 10.1080/00365521.2017.1383510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of computed tomography (CT) in acute pancreatitis (AP) continues to increase in parallel with the increasing use of diagnostic imaging in clinical medicine. AIM To determine the factors associated with obtaining >1 CT scan in acute interstitial pancreatitis (AIP). METHODS Demographic and clinical data of all adult patients admitted between 1/2010 and 1/2015 with AP (AP) were evaluated. Only patients with a CT severity index (CTSI) ≤ 3 on a CT obtained within 48 h of presentation were included. RESULTS A total of 229 patients were included, of whom 206 (90%) had a single CT and 23 (10%) had >1 CT during the first week of hospitalization. Patients undergoing >1 CT had significantly higher rates of acute fluid collection (AFC), persistent SIRS, opioid use ≥4 days, and persistent organ failure compared to those undergoing 1 CT (p < .05 for all). On multivariable analysis, only persistent SIRS (OR = 3.6, 95% CI 1.4-9.6, p = .01) and an AFC on initial CT (OR = 3.5, 95% CI 1.4-9, p = .009) were independently associated with obtaining >1 CT. CONCLUSION An AFC on initial CT and persistent SIRS are associated with increased CT imaging in AIP patients. However, these additional CT scans did not change clinical management.
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Affiliation(s)
- Ayesha Kamal
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Mahya Faghih
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Robert A Moran
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Elham Afghani
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Amitasha Sinha
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Nasim Parsa
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Martin A Makary
- b Division of Surgical Oncology, Department of Surgery , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Atif Zaheer
- c Pancreatitis Center, Johns Hopkins Medical Institutions , Baltimore , MD , USA.,d Department of Radiology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Elliot K Fishman
- d Department of Radiology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Mouen A Khashab
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Anthony N Kalloo
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA.,c Pancreatitis Center, Johns Hopkins Medical Institutions , Baltimore , MD , USA
| | - Vikesh K Singh
- a Division of Gastroenterology , Johns Hopkins Medical Institutions , Baltimore , MD , USA.,c Pancreatitis Center, Johns Hopkins Medical Institutions , Baltimore , MD , USA
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10
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Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis. Langenbecks Arch Surg 2017; 402:811-819. [PMID: 28434059 PMCID: PMC5506178 DOI: 10.1007/s00423-017-1581-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 06/15/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE The aim of this study was to compare the prognostic value of established scoring systems with early warning scores in a large cohort of patients with acute pancreatitis. METHODS In patients presenting with acute pancreatitis, age, sex, American Society of Anaesthesiologists (ASA) grade, Modified Glasgow Score, Ranson criteria, APACHE II scores and early warning score (EWS) were recorded for the first 72 h following admission. These variables were compared between survivors and non-survivors, between patients with mild/moderate and severe pancreatitis (based on the 2012 Atlanta Classification) and between patients with a favourable or adverse outcome. RESULTS A total of 629 patients were identified. EWS was the best predictor of adverse outcome amongst all of the assessed variables (area under curve (AUC) values 0.81, 0.84 and 0.83 for days 1, 2 and 3, respectively) and was the most accurate predictor of mortality on both days 2 and 3 (AUC values of 0.88 and 0.89, respectively). Multivariable analysis revealed that an EWS ≥2 was independently associated with severity of pancreatitis, adverse outcome and mortality. CONCLUSION This study confirms the usefulness of EWS in predicting the outcome of acute pancreatitis. It should become the mainstay of risk stratification in patients with acute pancreatitis.
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11
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Rasslan R, da Costa Ferreira Novo F, Rocha MC, Bitran A, de Souza Rocha M, de Oliveira Bernini C, Rasslan S, Utiyama EM. Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone. Clinics (Sao Paulo) 2017; 72:87-94. [PMID: 28273241 PMCID: PMC5314426 DOI: 10.6061/clinics/2017(02)04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/18/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.
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Affiliation(s)
- Roberto Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
- *Corresponding author. E-mail:
| | - Fernando da Costa Ferreira Novo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Marcelo Cristiano Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Alberto Bitran
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Manoel de Souza Rocha
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Radiologia e Oncologia, São Paulo/SP, Brazil
| | - Celso de Oliveira Bernini
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Samir Rasslan
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
| | - Edivaldo Massazo Utiyama
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Departamento de Cirurgia - Disciplina de Cirurgia Geral e Trauma, São Paulo/SP, Brazil
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Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, Coburn N, May GR, Pearsall E, McLeod RS. Clinical practice guideline: management of acute pancreatitis. Can J Surg 2016; 59:128-40. [PMID: 27007094 DOI: 10.1503/cjs.015015] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.
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Affiliation(s)
- Joshua A Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jonathan Hsu
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Mohammad Bawazeer
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - John Marshall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jan O Friedrich
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Avery Nathens
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Natalie Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Gary R May
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Emily Pearsall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Robin S McLeod
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
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Compliance with Evidence-Based Guidelines in Acute Pancreatitis: an Audit of Practices in University of Toronto Hospitals. J Gastrointest Surg 2016; 20:392-400. [PMID: 26621675 DOI: 10.1007/s11605-015-3023-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/05/2015] [Indexed: 01/31/2023]
Abstract
Despite existing evidence-based practice guidelines for the management of acute pancreatitis, clinical compliance with recommendations is poor. We conducted a retrospective review of 248 patients admitted between 2010 and 2012 with acute pancreatitis at eight University of Toronto affiliated hospitals. We included all patients admitted to ICU (52) and 25 ward patients from each site (196). Management was compared with the most current evidence used in the Best Practice in General Surgery Management of Acute Pancreatitis Guideline. Fifty-six patients (22.6 %) had only serum lipase tested for biochemical diagnosis. Admission ultrasound was performed in 174 (70.2 %) patients, with 69 (27.8 %) undergoing ultrasound and CT. Of non-ICU patients, 158 (80.6 %) were maintained nil per os, and only 18 (34.6 %) ICU patients received enteral nutrition, commencing an average 7.5 days post-admission. Fifty (25.5 %) non-ICU patients and 25 (48.1 %) ICU patients received prophylactic antibiotics. Only 24 patients (22.6 %) with gallstone pancreatitis underwent index admission cholecystectomy. ERCP with sphincterotomy was under-utilized among patients with biliary obstruction (16 [31 %]) and candidates for prophylactic sphincterotomy (18 [22 %]). Discrepancies exist between the most current evidence and clinical practice within the University of Toronto hospitals. A guideline, knowledge translation strategy, and assessment of barriers to clinical uptake are required to change current clinical practice.
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14
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Carioca AL, Jozala DR, Bem LOD, Rodrigues JMDS. Severity assessment of acute pancreatitis: applying Marshall scoring system. Rev Col Bras Cir 2015; 42:325-7. [DOI: 10.1590/0100-69912015005010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/21/2015] [Indexed: 01/21/2023] Open
Abstract
Objective: To analyze the effectiveness of the Marshall scoring system to evaluate the severity of acute pancreatitis (AP). Methods : We performed a prospective, observational study in 39 patients with AP evaluated by the Marshall scoring system and the Ranson criteria (admission and 48 hours). We assessed the progression of the disease for seven days and compared the data of the two criteria. Results : Seven patients died during the observation period and one died afterwards. All deaths had shown failure of at least one system by the Marshall method. Conclusion : The Marshall scoring system may be used as an effective and simplified application method to assess the severity of acute pancreatitis.
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15
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Minimally invasive necrosectomy using resectoscope for intractable necrotic abscess after severe acute pancreatitis: report of a case. Surg Today 2014; 45:1442-5. [PMID: 25382168 DOI: 10.1007/s00595-014-1063-5] [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: 09/20/2013] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
Abstract
CASE REPORT A 43-year-old male was admitted to a regional hospital after being diagnosed with severe acute pancreatitis. The patient developed a pancreatic abscess with multiple organ failure. He was transferred to our hospital in critical condition. Computed tomography scans revealed enormous pancreatic abscesses expanding from the pancreatic body to the pelvic area. Pigtail catheters were inserted for percutaneous drainage. Even after the drainage, the abscesses did not improve. Percutaneous necrosectomy was performed using a resectoscope through a fistulous tract. After two necrosectomies, the CT scans showed remarkable decreases in the size of the cystic abscesses, and finally, no abscesses were detectable on the 117 th hospital day. CONCLUSION We herein present the first description of a minimally invasive technique, using resectoscopy, for treating intractable pancreatic abscesses. Future studies are warranted to examine the efficacy and safety of this procedure for difficult cases, as presented in this report.
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16
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Zuidema MJ, van Santvoort HC, Besselink MG, van Ramshorst B, Boerma D, Timmer R, Bollen TL, Weusten BLAM. The predictive value of proteinuria in acute pancreatitis. Pancreatology 2014; 14:484-9. [PMID: 25287156 DOI: 10.1016/j.pan.2014.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 09/04/2014] [Accepted: 09/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP). METHODS This is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality. RESULTS Proteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03). CONCLUSION Proteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.
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Affiliation(s)
- M J Zuidema
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands.
| | - H C van Santvoort
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, The Netherlands
| | - B van Ramshorst
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital Nieuwegein, The Netherlands
| | - R Timmer
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - T L Bollen
- Department of Radiology, St. Antonius Hospital Nieuwegein, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology, St. Antonius Hospital Nieuwegein, The Netherlands
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Safari S, Rahmani F, Soleimanpour H, Ebrahimi Bakhtavar H, Mehdizadeh Esfanjani R. Can APACHE II Score Predict Diabetic Ketoacidosis in Hyperglycemic Patients Presenting to Emergency Department? Anesth Pain Med 2014; 4:e21365. [PMID: 25599026 PMCID: PMC4286803 DOI: 10.5812/aapm.21365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/29/2014] [Accepted: 08/15/2014] [Indexed: 11/17/2022] Open
Abstract
Background: Diabetic ketoacidosis (DKA) is an acute and life-threatening complication in diabetic patients. The current diagnostic criteria of DKA are metabolic acidosis, blood glucose level greater than 250 mg/dL and the presence of ketones in serum or urine. DKA patients referring to the emergency department (ED) are usually ill. Objectives: The present study aims to evaluate the efficacy of Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring in predicting the critically illness in the hyperglycemic patients referring to the ED. Patients and Methods: We performed a prospective cohort study in an ED. One hundred eighty one patients older than 18 years with hyperglycemia were included in our study. Following the primary evaluation, the subjects were divided into DKA and non-DKA patients. APACHE II scores were calculated for all patients and then compared to each other. We determined predictive value, sensitivity, specificity and cut-off points of APACHE II score for DKA. Results: Sixty two patients had DKA. The comparison of APACHE II score among two groups of the patients did not show any significant difference (P = 0.597). There was no suitable cut-off point for APACHE II score to predict DKA. Conclusions: APACHE II score cannot be applied in the predicting of DKA in hyperglycemic patients admitted in ED.
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Affiliation(s)
- Saeid Safari
- Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farzad Rahmani
- Emergency Medicine Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding author: Hassan Soleimanpour, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Daneshgah St., Tabriz, 51664, Iran. Tel: +98-9141164134, Fax: +98-4133352078, E-mail:
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Thandassery RB, Appasani S, Yadav TD, Dutta U, Indrajit A, Singh K, Kochhar R. Implementation of the Asia-Pacific guidelines of obesity classification on the APACHE-O scoring system and its role in the prediction of outcomes of acute pancreatitis: a study from India. Dig Dis Sci 2014; 59:1316-21. [PMID: 24374646 DOI: 10.1007/s10620-013-3000-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 12/11/2013] [Indexed: 12/28/2022]
Abstract
AIMS We studied the role of obesity and the Acute Physiology and Chronic Health Evaluation (APACHE) O score in predicting the outcome in patients with acute pancreatitis (AP) using the Asia-Pacific obesity classification. METHODS Two hundred eighty AP patients were classified into three different groups, normal weight [body mass index (BMI) = 18.5-22.9 kg/m(2)], overweight (BMI = 23-24.9 kg/m(2)) and obese (BMI > 25 kg/m(2)), according to the Asia-Pacific obesity classification. For all patients APACHE II scores and modified APACHE O (i.e., APACHE Oap) scores that included a factor for obesity were calculated. The patients were managed using a standard protocol, and the outcome measures were compared for different obesity groups. RESULTS Of the 280 patients (mean age 40.7 years), 46.8% were normal weight, 29.6% overweight and 23.6% obese. Forty-six (16.4%) patients underwent surgery, and 61 (21.8%) patients died. Patients with higher BMI had worse radiological indices of severity, more infected necrosis (p < 0.001), more persistent organ failure (p < 0.001) and higher requirement for percutaneous drain insertion (p = 0.04), surgery (p = 0.008) and mortality (p < 0.001). The area under the curve for predicting mortality was 0.879 for APACHE II and 0.886 for APACHE Oap; at a cutoff of 8.5, the APACHE II score had a sensitivity of 88.2% and specificity of 68.7%, and APACHE Oap 90.2 and 64.0%, respectively. CONCLUSIONS BMI ≥ 23 kg/m(2) was an important predictor of a severe disease course and fatal outcome in patients with AP. However, the predictive accuracy of APACHE Oap for mortality was similar to APACHE II.
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Affiliation(s)
- Ragesh Babu Thandassery
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Retrospective analysis of clinical problems concerning acute pancreatitis in one treatment center. GASTROENTEROLOGY REVIEW 2013; 8:320-6. [PMID: 24868277 PMCID: PMC4027824 DOI: 10.5114/pg.2013.38736] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 06/29/2013] [Accepted: 07/09/2013] [Indexed: 12/12/2022]
Abstract
Introduction Severe acute pancreatitis is still a difficult clinical problem, it is a challenge for medical teams, which should include the strategy of personalized medicine. In clinical observations, among patients with the fulminating course of acute pancreatitis developed during the first hours leading to irreversible multiorgan failure and death. Aim To evaluate the frequency of occurrence and analyze the progression and treatment of severe acute pancreatitis (AP) in patients hospitalized during the years 2004–2010 at the Clinical Surgery Ward. Material and methods One thousand and fifty patients treated for AP were included in the study; 97 patients with severe AP were subjected to a detailed clinical analysis. Results The average age of the patients was 52.8 years. Relapses occurred in 14.9% of patients. The severe form of acute pancreatitis was diagnosed in 97 patients, which accounts for 9.2% of all the illnesses, and occurred significantly more often in male patients (p < 0.01). The most frequent etiological factors were cholelithiasis (46.4%), and idiopathic pancreatitis (27.8%); alcohol consumption was responsible for 22.7% of the cases; the occurrence of both a bile-derivative and alcoholic factor was found in 3.1% of the cases. A worsening clinical state resulted in laparotomy in 26 patients (26.8%), and re-laparotomy in 5 patients. Necrosectomy was performed on 15 patients, of whom 33.3% died due to complications. The total mortality in severe AP was 38.1%. The average age of the deceased was 66.5. Early deaths within 14 days were noted in 78.4% of patients (n = 29) who died due to severe AP. Conclusions Severe AP in spite of implementing modern diagnosis and treatment methods is still associated with a high risk of death. Constant clinical observation and use of available prognostic scales are essential in improving AP prognoses.
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Singh RK, Poddar B, Baronia AK, Azim A, Gurjar M, Singhal S, Srivastava S, Saigal S. Audit of patients with severe acute pancreatitis admitted to an intensive care unit. Indian J Gastroenterol 2012; 31:243-52. [PMID: 22932963 DOI: 10.1007/s12664-012-0205-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Accepted: 05/31/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe acute pancreatitis (SAP) is a disease with high morbidity and mortality. We undertook a study of patients with SAP admitted to the intensive care unit (ICU) of a tertiary referral hospital. METHODS Between 2002 and 2007, 50 patients with SAP were admitted in our intensive care unit (ICU). Data were collected from their medical records and their clinical profile, course and outcome were retrospectively analyzed. Patients were categorized into survivor and nonsurvivor groups, and were further classified based on interventions such as percutaneous drainage and surgical necrosectomy. RESULTS SAP contributed 5 % of total ICU admissions during the study period. Median age of survivors (n = 20) was 34 against 44 years in nonsurvivors (n = 30). Median Acute Physiology and Chronic Health Evaluation (APACHE) II score in nonsurvivors was 16.5 (8-32) vs. 12.5 (5-20) in survivors (p = 0.002). Patients with APACHE II score ≥12 had mortality >80 % compared to 23 % with score <12 (p < 0.001). Median Sequential Organ Failure Assessment (SOFA) scores on admission and on days 3, 7, 14, and 21 were significantly higher in nonsurvivors compared to survivors (p < 0.05). Mean (SD) intraabdominal pressure was 23 (3.37) mmHg in nonsurvivors vs. 19.05 (2.51) in survivors (p < 0.05). Patients with renal failure had significant mortality (p < 0.001). Length of ICU stay, requirement for vasopressor, total parenteral nutrition, and the amount of blood and blood product transfusions differed significantly between patients with and without intervention. CONCLUSIONS APACHE II and SOFA scores and other clinical data correlated with outcome in SAP admitted to ICU.
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Affiliation(s)
- Ratender Kumar Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
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The day when infection is confirmed is a better time point for mortality prediction in patients with severe acute pancreatitis. Pancreas 2012; 41:605-10. [PMID: 22441144 DOI: 10.1097/mpa.0b013e31823a3b39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The objective of the study was to compare the accuracy of predictive methods for mortality in patients with severe acute pancreatitis (SAP) on admission and on the day when infection was confirmed. METHODS Medical records of patients admitted for SAP in our hospital during January 2000 to November 2010 were retrospectively reviewed. Among those with infectious complications, time when infection was confirmed (TIC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission and at the time when infection was confirmed (APACHE II OTIC) were studied. The correlations among the APACHE II score on admission, APACHE II OTIC score, and TIC were analyzed. The predictive accuracy was assessed by the area under the receiver operating characteristic curve. RESULTS Time when infection was confirmed correlated negatively with the APACHE II score on admission and the APACHE II OTIC score (P < 0.05). The optimum cutoff value and the corresponding areas under the receiver operating characteristic curve for APACHE II score on admission, APACHE II OTIC score, and TIC were greater than 8, greater than 5, 12 days or less, and 0.67 (95% confidence interval [CI], 0.54-0.77), 0.84 (95% CI, 0.73-0.91), and 0.73 (95% CI, 0.61-0.82), respectively. Compared with the APACHE II score on admission, the APACHE II OTIC score was more accurate in predicting mortality (P = 0.029). CONCLUSIONS The time when infection is confirmed is a better time point for the reassessment of the outcome in patients with SAP.
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Shin KY, Lee WS, Chung DW, Heo J, Jung MK, Tak WY, Kweon YO, Cho CM. Influence of obesity on the severity and clinical outcome of acute pancreatitis. Gut Liver 2011; 5:335-9. [PMID: 21927663 PMCID: PMC3166675 DOI: 10.5009/gnl.2011.5.3.335] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Accepted: 03/24/2011] [Indexed: 12/20/2022] Open
Abstract
Background/Aims Obesity tends to be associated with increased mortality and morbidity in acute pancreatitis. However, in Asian populations, higher morbidity and mortality have been reported in patients with low body mass indexes (BMIs). This study was undertaken to evaluate the relation between obesity and outcome, and to investigate the occurrence of complications by overweightedness in acute pancreatitis. Methods The medical records of 403 patients with acute pancreatitis were reviewed retrospectively, and Ranson's scores, modified Glasgow scores, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and computed tomography severity indexes were calculated. Patients were categorized by BMI for the analysis. Results When compared with normal patients (BMI 18.5 to 22.9), all categories with a BMI ≥23 had an increased risk of developing a severe form of acute pancreatitis (p=0.003) and all categories with a BMI ≥25 significantly predicted severity (p<0.001). Patients with class 1 obesity (BMI 25 to 29.9) developed significantly more systemic and metabolic complications. Conclusions Overweightedness and obesity were found to be associated with a higher risk of developing severe pancreatitis. Further studies are needed to establish the precise prognostic value of obesity in members of the population with low BMIs.
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Affiliation(s)
- Keun Young Shin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Beenen E, Brown L, Connor S. A comparison of the hospital costs of open vs. minimally invasive surgical management of necrotizing pancreatitis. HPB (Oxford) 2011; 13:178-84. [PMID: 21309935 PMCID: PMC3048969 DOI: 10.1111/j.1477-2574.2010.00267.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infected necrotizing pancreatitis is a major burden for both the patient and the health care system. Little is known about how hospital costs break down and how they may have shifted with the increasing use of minimally invasive techniques. The aim of this study was to analyse inpatient hospital costs associated with pancreatic necrosectomy. METHODS A prospective database was used to identify all patients who underwent an intervention for necrotizing pancreatitis. Costs of treatment were calculated using detailed information from the Decision Support Department. Costs for open and minimally invasive surgical modalities were compared. RESULTS Twelve open and 13 minimally invasive necrosectomies were performed in a cohort of 577 patients presenting over a 50-month period. One patient in each group died in hospital. Overall median stay was 3.8 days in the intensive care unit (ICU) and 44 days on the ward. The median overall treatment cost was US$ 56,674. The median largest contributors to this total were ward (26.3%), surgical personnel (22.3%) and ICU (17.0%) costs. These did not differ statistically between the two treatment modalities. CONCLUSIONS Pancreatic necrosectomy uses considerable health care resources. Minimally invasive techniques have not been shown to reduce costs. Any intervention that can reduce the length of hospital and, in particular, ICU stay by reducing the incidence of organ failure or by preventing secondary infection is likely to be cost-effective.
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Affiliation(s)
- Edwin Beenen
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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Sotoudehmanesh R, Hooshyar A, Kolahdoozan S, Zeinali F, Shahraeeni S, Keshtkar AA. Prognostic value of endoscopic ultrasound in acute pancreatitis. Pancreatology 2011; 10:702-6. [PMID: 21242710 DOI: 10.1159/000320695] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 08/20/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Endoscopic ultrasonography (EUS) is a useful modality to diagnose causes of pancreatitis. The role of EUS for prediction of pancreatitis severity has not been studied. The aim of this study was to identify the utility of EUS in determining the severity of acute pancreatitis (AP). METHODS All patients diagnosed with pancreatitis consecutively underwent EUS on the 2nd day of their admission. Atlanta criteria were used as the severity index of pancreatitis. RESULTS During the study period, 114 patients (74 females, 40 males; mean age of 53.03 ± 17.7 years) were enrolled in the study. The most common cause of AP was gallstone (78.9%). According to the Atlanta criteria, pancreatitis was mild in 72 (63.2%) and severe in 42 (36.8%) patients. In univariate analysis, the presence of peripancreatic edema, pancreas inhomogeneity, common bile duct dilation and ascites were associated with severe pancreatitis. In multivariate analysis, only the presence of peripancreatic edema in EUS correlated with the severity of AP according to the Atlanta criteria (sensitivity, specificity and accuracy: 65.8, 75.7 and 72.2%, respectively). CONCLUSION EUS may be a new useful imaging modality for prediction of severity of AP and may have prognostic significance in the early phase of AP. and IAP.
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Affiliation(s)
- Rasoul Sotoudehmanesh
- Digestive Diseases Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. setoodeh @ ams.ac.ir
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Magnetic resonance imaging versus Acute Physiology And Chronic Healthy Evaluation II score in predicting the severity of acute pancreatitis. Eur J Radiol 2010; 80:637-42. [PMID: 20843620 DOI: 10.1016/j.ejrad.2010.08.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 08/07/2010] [Accepted: 08/11/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To study the correlation between established magnetic resonance (MR) imaging criteria of disease severity in acute pancreatitis and the Acute Physiology And Chronic Healthy Evaluation II (APACHE II) score, and to assess the utility of each prognostic indicators in acute pancreatitis. MATERIALS AND METHODS In this study there were 94 patients with acute pancreatitis (AP), all had abdominal MR imaging. MR findings were categorized into edematous and necrotizing AP and graded according to the MR severity index (MRSI). The APACHE II score was calculated within 24h of admission, and local complications, death, duration of hospitalization and ICU were recorded. Statistical analysis was performed to determine their correlation. RESULTS In patients with pancreatitis, no significant correlation can be found between the APACHE II score and the MRSI score (P=0.196). The MRSI score correlated well with morbidity (P=0.006) but not with mortality (P=0.137). The APACHE II score correlated well with mortality (P=0.002) but not with the morbidity (P=0.112). The MRSI score was superior to the APACHE II score as a predictor of the length of hospitalization (r=0.52 vs. r=0.35). A high MRSI and APACHE II score correlated with the need for being in the intensive care unit (ICU) (P=0.000 and P=0.000, respectively). CONCLUSION In patients with pancreatitis, MRSI is superior to APACHE II in assessing local complications from pancreatitis but has a limited role in determining systemic complications in which the APACHE II score excels.
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Abstract
OBJECTIVES High serum creatinine is a well-known unfavorable prognostic parameter in acute pancreatitis. Elevated creatinine at 48 h after admission was recently described as a marker for pancreatic necrosis. As pancreatic necrosis is a serious complication of acute pancreatitis and its identification by a simple single laboratory test would be very helpful, the aim of this study was to test that statement. METHODS In a prospective multicenter study of 462 patients with a first attack of acute pancreatitis, serum creatinine was determined on admission, and at 24 and 48 h thereafter, and compared with the findings of contrast-enhanced computed tomography (CT) performed within 96 h of admission. RESULTS Pancreatic necrosis was present in 62 (13%) of the patients. Serum creatinine levels (abnormal > or = 2 mg/dl) on admission and after 24 and 48 h were evaluated vs. the presence or absence of pancreatic necrosis. Sensitivity rates varied between 14 and 23%, specificity between 95 and 97%, positive predictive values between 41 and 50%, and negative predictive values between 87 and 89%. Receiver operating characteristic curves revealed an area under the curve of between 0.604 and 0.669. CONCLUSIONS An elevated serum creatinine concentration at any time during the first 48 h of admission is not a marker for pancreatic necrosis in a first attack of acute pancreatitis. If serum creatinine is normal, necrotizing pancreatitis is unlikely, and contrast-enhanced CT need not be performed unless complications occur and/or the patient's condition deteriorates.
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Scaglione M, Casciani E, Pinto A, Andreoli C, De Vargas M, Gualdi GF. Imaging assessment of acute pancreatitis: a review. Semin Ultrasound CT MR 2009; 29:322-40. [PMID: 18853839 DOI: 10.1053/j.sult.2008.06.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.
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Affiliation(s)
- Mariano Scaglione
- Department of Diagnostic Imaging, Clinica Pineta Grande, Castel Volturno, Caserta, Italy.
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Schütte K, Malfertheiner P. Markers for predicting severity and progression of acute pancreatitis. Best Pract Res Clin Gastroenterol 2008; 22:75-90. [PMID: 18206814 DOI: 10.1016/j.bpg.2007.10.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Kerstin Schütte
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany
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Perfusion computerized tomography can predict pancreatic necrosis in early stages of severe acute pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1484-92. [PMID: 17950676 DOI: 10.1016/j.cgh.2007.07.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The mortality rate associated with severe acute pancreatitis (SAP) with necrosis remains high because early prediction of pancreatic necrosis is difficult. We evaluated whether perfusion computerized tomography (CT), which is used to identify early stage ischemia in the brain, could detect ischemic changes in the pancreas in the early stages of SAP and predict development of necrosis. PATIENTS AND METHODS Thirty consecutive patients with a diagnosis of SAP according to the Atlanta criteria and whose score was greater than 6 were enrolled in this study. All patients were hospitalized within 3 days after onset of symptoms indicative of acute pancreatitis and underwent perfusion CT. Three weeks later, all patients underwent conventional contrast-enhanced CT to detect progression of their disease. RESULTS Perfusion CT showed that 10 of the 30 patients had pancreatic ischemia at the time of diagnosis. Contrast-enhanced CT disclosed that pancreatic necrosis developed in 9 of these 10 patients, but not in the 20 patients who did not have pancreatic ischemia. The sensitivity and specificity of perfusion CT for predicting pancreatic necrosis was calculated to be 100% and 95.3%, respectively. CONCLUSIONS Perfusion CT is a useful tool for early detection of ischemic changes in the pancreas that lead to pancreatic necrosis.
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Triantopoulou C, Lytras D, Maniatis P, Chrysovergis D, Manes K, Siafas I, Papailiou J, Dervenis C. Computed tomography versus Acute Physiology and Chronic Health Evaluation II score in predicting severity of acute pancreatitis: a prospective, comparative study with statistical evaluation. Pancreas 2007; 35:238-42. [PMID: 17895844 DOI: 10.1097/mpa.0b013e3180619662] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of the study was to compare Acute Physiology and Chronic Health Evaluation II score and C-reactive protein as a clinical index and computed tomography-based severity index (CTSI) in predicting the course of acute pancreatitis. METHODS One hundred forty-eight patients with acute pancreatitis were enrolled in the study during a 2-year period. All data concerning etiology, Atlanta classification, CT findings, Acute Physiology and Chronic Health Evaluation score, C-reactive protein levels, stay in the intensive care unit, length of hospital stay, treatment, complications, and deaths were analyzed with Mann-Whitney U, Wilcoxon, Pearson, and Spearman statistical tests. The CT was performed on a spiral unit after intravenous administration of contrast material. Images were graded according to the Balthazar-CTSI scoring system. RESULTS A very good correlation was noticed between Balthazar-CTSI scores and local complications, whereas no statistically significant correlation was found between CT scores and stay in the intensive care unit. Among survivors and nonsurvivors, there were no statistically significant differences as far as CT scores were concerned. CONCLUSIONS Although the extent of necrosis as defined on contrast-enhanced CT examinations is considered as a risk factor for a negative prognosis, our findings suggest that the initially documented disease severity according only to imaging parameters is not highly important for the final patient outcome.
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Affiliation(s)
- Peter A Banks
- Division of Gastroenterology, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Knoepfli AS, Kinkel K, Berney T, Morel P, Becker CD, Poletti PA. Prospective study of 310 patients: can early CT predict the severity of acute pancreatitis? ACTA ACUST UNITED AC 2006; 32:111-5. [PMID: 16944038 DOI: 10.1007/s00261-006-9034-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 06/08/2006] [Indexed: 01/21/2023]
Abstract
BACKGROUND This study was designed to determine the most important early CT parameters predictive of acute pancreatitis severity. METHODS Three hundred and seventy-one consecutive patients with acute abdominal pain and hyperamylasemia were enrolled. Three hundred and ten of the 371 patients met our inclusion criteria. Acute pancreatitis severity was evaluated using the 1992 Atlanta criteria. Different CT parameters were reported from the admission abdominal CT by two radiologists blinded from any clinical parameter, but the patients' age and gender. These variables were fitted in a binary logistic regression model. RESULTS Acute pancreatitis was mild in 80% cases, severe in 20% cases and lethal in 12.69% cases. The following CT parameters were significantly associated with the severity of acute pancreatitis: the objective size of the pancreas (P = 0.001), the peripancreatic fat abnormalities (P = 0.001) and the extent of necrosis (P = 0.007). Moreover, the age of the patient revealed itself a highly significant (P = 0.001) indicator of disease severity. The association of the four CT criteria eventually showed a sensitivity of 73% and a specificity of 81% to predict acute pancreatitis severity. CONCLUSION Although these criteria correlated with disease severity, our study identified that morphological CT criteria cannot be used to triage patients with severe and mild acute pancreatitis.
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Affiliation(s)
- A-S Knoepfli
- Department of Radiology, Geneva University Hospital, Geneva, Switzerland.
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Sekimoto M, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, Hirota M, Kimura Y, Takeda K, Isaji S, Koizumi M, Otsuki M, Matsuno S. JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. ACTA ACUST UNITED AC 2006; 13:10-24. [PMID: 16463207 PMCID: PMC2779368 DOI: 10.1007/s00534-005-1047-3] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100 000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%–7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1–2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%–20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%–40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.
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Affiliation(s)
- Miho Sekimoto
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto 606-8501, Japan
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Carneiro MC, Manso JEF, Eulálio JMR, Renteria JM, Costa MD. O papel da avaliação inicial simplificada no prognóstico da pancreatite aguda. Rev Col Bras Cir 2006. [DOI: 10.1590/s0100-69912006000300007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJETIVO: Correlacionar a avaliação clínico-laboratorial inicial simplificada com a gravidade da pancreatite aguda e a presença de necrose. MÉTODO: Foi realizado um estudo retrospectivo dos pacientes com diagnóstico final de PA internados no Hospital Universitário Clementino Fraga Filho - UFRJ entre janeiro de 1990 e agosto de 2002. Foi considerado apenas o primeiro episódio de cada paciente. Os dados obtidos foram submetidos a análise estatística. Foram estudados 164 pacientes onde a idade média foi de 43,7 anos. RESULTADOS: A etiologia biliar foi a mais freqüente com 43,9% dos casos. A incidência de necrose foi de 21,3% e a mortalidade global de 23,2%. Observamos que a ausência de taquicardia na admissão estava associada à forma branda da doença, e que os níveis plasmáticos de uréia e creatinina elevados na admissão estão associados à forma grave da doença, e a hiperglicemia (121mg/dl) à necrose pancreática. CONCLUSÕES: A avaliação inicial simplificada ainda tem espaço, embora que limitado, no acompanhamento do paciente com PA.
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Stimac D, Fisić E, Milić S, Bilić-Zulle L, Perić R. Prognostic values of IL-6, IL-8, and IL-10 in acute pancreatitis. J Clin Gastroenterol 2006; 40:209-12. [PMID: 16633121 DOI: 10.1097/00004836-200603000-00007] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
GOALS The prognostic importance of interleukin-6 (IL-6), IL-8, and IL-10 in the prediction of acute pancreatitis severity. BACKGROUND Early assessment of severity in acute pancreatitis could help the patients who are at risk of developing complications. Unfortunately, the used prognostic scoring systems generally are only moderately accurate in assessing disease severity. STUDY We studied 117 consecutive patients with a diagnosis of acute pancreatitis admitted to our hospital during the past 2 years. Laboratory parameters and cytokines were analyzed from serum taken routinely on admission. Severity criteria were noted for each patient using Ranson, Glasgow, and APACHE II scoring systems. Local and systemic complications, developed during a follow-up period, were classified by Atlanta criteria. RESULTS IL-6 was the only parameter that statistically significantly predicted complicated acute pancreatitis (P<0.05). IL-8 and IL-10 and the 3 prognostic scoring systems used did not properly assess complicated versus noncomplicated acute pancreatitis. CONCLUSIONS Our prospective study supported the potential importance of IL-6 in the early assessment of complicated acute pancreatitis, but also suggested that pancreatitis classified as complicated in a large number of patients could not be correctly predicted with the Ranson, Glasgow, and APACHE II scoring systems.
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Affiliation(s)
- Davor Stimac
- Division of Gastroenterology, Department of Internal Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
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Niederau C, Hippenstiel J. Conservative management of acute pancreatitis: complications and outcome in a community-based hospital. Pancreas 2006; 32:67-79. [PMID: 16340747 DOI: 10.1097/01.mpa.0000194608.16982.33] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Acute pancreatitis remains a potentially life-threatening disease. Despite national and international consensus conferences, the management of acute pancreatitis still differs among hospitals and countries. METHODS This study analyzes the outcome of acute pancreatitis treated by a conservative strategy in a community-based hospital. The strategy followed a conservative interpretation of German consensus guidelines but did not determine medical decisions by a prospective protocol. RESULTS The analysis included 145 patients treated for acute pancreatitis in the St. Josef Hospital Oberhausen from 1998 to 2002. The etiology was alcoholic in 54.5% and biliary in 26.2% of patients (other causes, 18.6%). Only 1 patient died of septic multiorgan failure (mortality, 1/145; 0.7%). Severe complications occurred in only 22 patients, including renal failure (n = 7), ileus (n = 6), respiratory or cardiac failure (n = 7), need for surgery (n = 4), and sepsis (n = 11). Further complications included pneumonia, delirium, choledocholithiasis/cholecystitis, diabetes mellitus, convulsions, gastric/duodenal ulcers, and pericardial effusion. Of the 145 patients, 75 subjects had at least 1 complication. Fine-needle puncture, mechanical ventilation, hemoperfusion, and hemodialysis were rarely necessary. Computed tomography (CT) was performed in only 69 of 145 patients (47.6%) and showed pancreatic necrosis in 27 of the 69 patients. Maximal C-reactive protein during the first 72 hours and CT findings proved useful in predicting the outcome in univariate analyses. By logistic regression, however, complication rates were associated with Ranson score, but not with CT findings, C-reactive protein, sex, age, etiology, or serum enzymes. CONCLUSIONS A conservative management of acute pancreatitis in a community-based hospital results in a low rate of complications, mortality, and costs. Clinical assessment (eg, by Ranson score) is sufficient to predict the severity of pancreatitis in most patients. In this cohort, none of the patients were transferred to a specialized center over a 5-year period. Thus, almost all patients with acute pancreatitis can adequately and cost-effectively be cared for in community-based hospitals when following conservative guidelines.
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Affiliation(s)
- Claus Niederau
- Katholische Kliniken Oberhausen GmbH, Department of Medicine, St. Josef Hospital, Oberhausen, Germany.
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Pearce CB, Gunn SR, Ahmed A, Johnson CD. Machine learning can improve prediction of severity in acute pancreatitis using admission values of APACHE II score and C-reactive protein. Pancreatology 2005; 6:123-31. [PMID: 16327290 DOI: 10.1159/000090032] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 07/18/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute pancreatitis (AP) has a variable course. Accurate early prediction of severity is essential to direct clinical care. Current assessment tools are inaccurate, and unable to adapt to new parameters. None of the current systems uses C-reactive protein (CRP). Modern machine-learning tools can address these issues. METHODS 370 patients admitted with AP in a 5-year period were retrospectively assessed; after exclusions, 265 patients were studied. First recorded values for physical examination and blood tests, aetiology, severity and complications were recorded. A kernel logistic regression model was used to remove redundant features, and identify the relationships between relevant features and outcome. Bootstrapping was used to make the best use of data and obtain confidence estimates on the parameters of the model. RESULTS A model containing 8 variables (age, CRP, respiratory rate, pO2 on air, arterial pH, serum creatinine, white cell count and GCS) predicted a severe attack with an area under the receiver-operating characteristic curve (AUC) of 0.82 (SD 0.01). The optimum cut-off value for predicting severity gave sensitivity and specificity of 0.87 and 0.71 respectively. The predictions were significantly better (p = 0.0036) than admission APACHE II scores in the same patients (AUC 0.74) and better than historical admission APACHE II data (AUC 0.68-0.75). CONCLUSIONS This system for the first time combines admission values of selected components of APACHE II and CRP for prediction of severe AP. The score is simple to use, and is more accurate than admission APACHE II alone. It is adaptable and would allow incorporation of new predictive factors.
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Affiliation(s)
- Callum B Pearce
- Department of Gastroenterology, Southampton General Hospital, Southampton, UK.
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Vriens PW, van de Linde P, Slotema ET, Warmerdam PE, Breslau PJ. Computed Tomography Severity Index Is an Early Prognostic Tool for Acute Pancreatitis. J Am Coll Surg 2005; 201:497-502. [PMID: 16183486 DOI: 10.1016/j.jamcollsurg.2005.06.269] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 05/19/2005] [Accepted: 06/01/2005] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute pancreatitis is a severe disease with unpredictable course and outcomes. It is especially hard to identify early those patients who will have a fulminant course. In a prospective observational study, we tested the hypothesis that the CT Severity Index (CTSI), established within 48hours after admission, is prognostic for morbidity and mortality and can predict the necessity for admission to an ICU. STUDY DESIGN From January 1994 to October 2002, all patients with the diagnosis of first time acute pancreatitis underwent spiral CT with intravenous contrast within 48hours of admission. The extent of inflammation and necrosis was assessed to define the CTSI. Patients were initially managed in an ICU in a standardized fashion. Complications and mortality were registered in a systematic manner. RESULTS Seventy-nine patients were admitted with acute pancreatitis. The overall complication rate was 57%; mortality was 9%. In patients with a CTSI of 0 to 3, these rates were 42% and 2%, respectively; in those with CTSI of 4 to 6, 81% and 19%, respectively; and in those with CTSI of 7 to 10, 100% and 33%, respectively. Outcomes of subsequent CT scans did not alter the initial prognosis. Early CTSI correlated well with the incidence of complications, sepsis, mortality, and necessity for ICU admission. CONCLUSIONS Acute pancreatitis is associated with marked morbidity and mortality. Initial admission to an ICU and standardized conservative treatment are justified for all patients. Early establishment of the CTSI is an excellent prognostic tool for complications and mortality. Patients with a CTSI of 0 to 3 can safely be discharged from the ICU.
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Affiliation(s)
- Patrick W Vriens
- Department of Surgery, Rode Kruis Ziekenhuis, The Hague, The Netherlands
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Papachristou GI, Sass DA, Avula H, Lamb J, Lokshin A, Barmada MM, Slivka A, Whitcomb DC. Is the monocyte chemotactic protein-1 -2518 G allele a risk factor for severe acute pancreatitis? Clin Gastroenterol Hepatol 2005; 3:475-81. [PMID: 15880317 DOI: 10.1016/s1542-3565(05)00163-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute pancreatitis (AP) reflects the intensity of the inflammatory response and is divided into mild AP (MAP) or severe AP (SAP). Monocyte chemotactic protein-1 (MCP-1) gene expression is altered by an A/G polymorphism (-2518), with the G allele increasing MCP-1 production. Our aim was to determine whether the MCP-1 -2518 A/G polymorphism affects the severity of AP. METHODS Seventy-seven consecutive patients and 116 controls were evaluated. The A/G genotype was evaluated by polymerase chain reaction amplification, restriction fragment length polymorphism, and DNA sequencing. MCP-1 serum levels were quantified using a fluorescence bead-based immunoassay. RESULTS Sixty-three of 77 patients had MAP (82%) and 14 of 77 had SAP (18%). Patients with SAP had a significantly greater proportion of the G allele (12 of 14; 86%) than did control subjects (50 of 116; 43%) (odds ratio [OR], 7.9; 95% confidence interval [CI], 1.7-37, P < .003) or MAP patients (29 of 63; 46%) (OR, 7.0; 95% CI, 1.5-34; P < .007). Patients with pancreatitis and AA genotype had a low risk for SAP (OR, .13; 95% CI, .01-.61; P < .003). As predicted by the genotype, the serum MCP-1 levels were significantly higher in the SAP patients when compared with the MAP patients ( P = .002) and they also predicted death. CONCLUSIONS MCP-1 -2518 G allele is a risk factor for severe AP. MCP-1 serum levels, measured early in the course of AP, appear to be an accurate predictor of severity of acute pancreatitis and death.
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Abstract
This review will present recent findings and emerging questions on the major diseases of the pancreas: acute and chronic pancreatitis as well as pancreatic carcinoma. It is now clear that acute pancreatitis is initiated inside acinar cells by premature activation of digestive enzymes and disturbances of intracellular calcium. The release of proinflammatory mediators expands the local disturbances to a systemic inflammatory response. The transfer of these findings into clinical management had only limited success so far. Genetic mutations have been identified as pathogenetic factors in hereditary pancreatitis and are increasingly detected in patients with idiopathic chronic pancreatitis. In pancreatic carcinoma and in putative premalignant lesions, different alterations in cancer causing genes have been identified. Pancreatic cancer is at large a signal transduction disease leading to unregulated cell proliferation and migration. All three pancreatic diseases are characterized by profound alterations of extracellular matrix (ECM) formation. Essential data concerning composition and regulation of ECM has emerged after the description of the pancreatic stellate cell.
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Affiliation(s)
- Guido Adler
- Department of Internal Medicine I, University of Ulm, Robert-Koch-Str. 8, 89081 Ulm, Germany.
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Abstract
The fate of a patient with acute pancreatitis largely depends on early recognition of the severity of the disease. Acute pancreatitis is severe when organ failure and/or pancreatic necrosis occur. Whereas simple and low cost parameters are available for the detection of organ failure, the detection and extent of pancreatic necrosis requires a costly contrast-enhanced computed tomography. This is not always available in all institutions. This review article which considers when the clinician should be concerned about his patient diagnosed with acute pancreatitis, summarizes possibilities for diagnosing clinical severe (that is organ failure) and radiological severe (that is the necrotizing form of the disease) pancreatitis using simple and inexpensive parameters which are available everywhere. At present, a CT scan should be performed in those patients with alcohol etiology, those admitted to hospital early (time interval between the onset of symptoms and admission to hospital of less than 24 h, those presenting with rebound tenderness and/or guarding, a lipase >1,000 U/l, as well as a raised hematocrit and blood glucose. The evaluation, furthermore, shows that some parameters have a sufficiently high negative predictive value of >90%, which may render a contrast-enhanced CT scan unnecessary in the early stages, unless the patient fails to improve. These parameters include non-alcohol etiology, time interval between onset and admission to hospital longer than 24 h, no guarding or rebound tenderness on admission, low or normal hematocrit and nonelevated blood glucose. It is necessary to look further on simple low cost and more valid parameters on admission in order to reliably distinguish between necrotizing pancreatitis and interstitial pancreatitis.
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Affiliation(s)
- Paul Georg Lankisch
- Department of Internal Medicine, Municipal Clinic of Lüneburg, Lüneburg, Germany.
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Abstract
Acute pancreatitis is associated with significant morbidity and a mortality rate of approximately 8%. In severe pancreatitis, necrosis at the site of inflammation and remote organ failure develop in the course of disease. Pancreatic injury is initiated by molecular events in acinar cells. Premature activation of digestive enzymes, disturbances of intracellular calcium, and activation of transcription factors such as NF-kappaB characterize the initial phase of acute pancreatitis. The release of proinflammatory mediators and the recruitment of immune cells expand the local disturbances to a systemic inflammatory response associated with failure of distant organs such as lungs or kidney. The use of transgenic or knockout mice together with classic models of secretagogue-induced pancreatitis has provided considerable insight into the role of individual cellular or humoral factors in different stages of experimental pancreatitis. Transfer of these findings into clinical management or novel therapeutic strategies so far has had only very limited success. This may be due to the limitation of pancreatitis models to mimic completely the human disease. Therefore, a distinction between experimental models and clinical acute pancreatitis has to be maintained. The first part of this review will therefore concentrate on the initiation of acinar cell injury in experimental pancreatitis. Novel insights covering the mechanism by which local pancreatic involvement expands into systemic inflammation described in the second part. Progress in the clinical management and treatment of acute pancreatitis in humans is the focus of the third part of this review.
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Kusnierz-Cabala B, Kedra B, Sierzega M. Current concepts on diagnosis and treatment of acute pancreatitis. Adv Clin Chem 2003; 37:47-81. [PMID: 12619705 DOI: 10.1016/s0065-2423(03)37006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- B Kusnierz-Cabala
- Department of Clinical Biochemistry, Collegium, Medicum Jagiellonian University, Krakow, Poland
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Affiliation(s)
- Evan L Fogel
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indaianpolis, 46202-5280, USA.
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Abstract
While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency--if occurring--is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.
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Affiliation(s)
- S Wagner
- Medizinische Klinik II, Klinikum Deggendorf
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Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc 2002. [PMID: 12447272 DOI: 10.1016/s0016-5107(02)70016-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Peter A Banks
- Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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