Prevalence and predictors of severity as defined by atlanta criteria among patients presenting with acute pancreatitis

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission

Background

Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality.

Methods

A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS.

Result

Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052–1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012–1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000–1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients’ age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548–0.661).

Conclusions

Patients’ age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: assessment of effectiveness and safety

OBJECTIVE

The purpose of this study is to assess retrospectively the effectiveness and safety of CT-guided percutaneous drainage and to determine the factors influencing clinical success and mortality in patients with infectious necrotizing pancreatitis.

MATERIALS AND METHODS

From April 1997 to December 2005, 48 consecutive patients (33 men and 15 women; median age, 58.5 years) with proven infectious necrotizing pancreatitis underwent percutaneous catheter drainage via CT guidance. Evaluated factors included clinical, biologic, and radiologic scores; drainage and catheter characteristics; and complications. Clinical success was defined as control of sepsis without requirement for surgery. Univariate analysis was performed to determine factors that could have affected the clinical success and the mortality rates.

RESULTS

Clinical success was achieved in 31 of 48 patients (64.6%) and was significantly associated with Ranson score (p = 0.01) and with the delay between admission and the beginning of the drainage (p = 0.005), with a calculated threshold delay of 18 days (p = 0.001). The global mortality rate (14/48 [29%]) was also influenced by the Ranson score (p = 01) and the delay of drainage (p = 0.04) with the same threshold delay (p = 0.01). Only two major nonlethal procedure-related complications were observed.

CONCLUSION

Percutaneous catheter drainage is a safe and effective technique to treat acute infectious necrotizing pancreatitis.

Soluble angiogenic factors in patients with acute pancreatitis

BACKGROUND

Angiogenic factors are involved in the physiopathology of several inflammatory diseases and they probably play a role in the pathogenesis of acute pancreatitis (AP).

AIMS

To investigate if angiogenic factors are elevated in patients with AP, their relationship with severity and clinical evolution of AP, and their use as prognosis markers of AP.

METHODS

A case (25)-control (30) study was carried out. Patients with AP were classified according to severity (using Ranson and Glasgow scores) and according to their clinical evolution (taking into account the development of complications during hospital stay). Platelet-derived growth factor (PDGFBB), angiopoietin-1, angiopoietin-2 (Ang-2), angiopoietin tyrosine-kinase receptor, hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), VEGF tyrosine-kinase receptor 1, and VEGF tyrosine-kinase receptor 2 were determined at 12 hours and then at 5 days after hospitalization.

RESULTS

PDGFBB, Ang-2, angiopoietin tyrosine-kinase receptor, and HGF were significantly higher in cases (P<0.001), and in patients with unfavorable clinical evolution (P<0.001). PDGFBB and HGF were significantly higher in patients with severe AP (P<0.05). To predict unfavorable clinical evolution, PDGFBB, Ang-2, and HGF showed an area under receiver operating characteristic curve of 0.97.

CONCLUSIONS

PDGFBB and HGF are related to severity of AP. These factors along with Ang-2 are related to clinical evolution and are useful in predicting the development of several complications during hospital stay. Therefore, these angiogenic factors could be useful as prognosis markers of AP.

Estimation of physiologic ability and surgical stress score does not predict immediate outcome after pancreatic surgery

OBJECTIVE

The Estimation of Physiologic Ability and Surgical Stress score was designed to predict postoperative morbidity and mortality in general surgery. Our study aims to evaluate its use and accuracy in estimating postoperative outcome after elective pancreatic surgery.

METHODS

Between 2002 and 2007, approximately 304 patients requiring pancreatic resection at our institution were recorded prospectively and evaluated retrospectively. The patients' preoperative risk score, surgical stress score (SSS), and comprehensive risk score (CRS) were calculated and compared with the severity of postoperative morbidity, where mortality was regarded as the most severe postoperative complication.

RESULTS

Observed and predicted mortality rates were 2.9% and 2.0%, respectively. Mean CRS was higher in patients who died than in patients that survived, but this difference was not statistically significant (P = 0.20). Preoperative risk score, SSS, and CRS did not differ between patients with and without complications (preoperative risk score: P = 0.32; SSS: P = 0.22; CRS: P = 0.13). Estimation of Physiologic Ability and Surgical Stress particularly underpredicted morbidity in patients with a CRS between 0.0 and less than 0.5.

CONCLUSIONS

The Estimation of Physiologic Ability and Surgical Stress scoring system is an ineffective predictor of complications after pancreatic resection. Further refinements to the score calculation are warranted to provide accurate prediction of immediate surgical outcome after pancreatic surgery.

Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis

OBJECTIVE

Several tools have been developed for severity stratification in acute pancreatitis (AP). They include single biochemical markers and complex scoring systems, all of which aim at an early detection of severe AP to optimize monitoring and treatment of these patients. The aim of this study was to reassess and compare the value of some known and newly-introduced prognostic markers in the clinical context.

MATERIAL AND METHODS

We have conducted a prospective observational study. One hundred and eight patients with a diagnosis of AP and onset of the disease within last 72 h were included in this study. Clinical data and expression results of some serum biochemical markers were used for statistical analysis. The diagnostic performance of scores predicting severity and progression of AP, cut-off values, specificity, and sensitivity were established using receiver operating characteristic curve analysis.

RESULTS

Among single biochemical markers, C-reactive protein remains the most useful. Despite its delayed increase, it is accurate, cheap, and widely available. Interleukin-6 and macrophage migration inhibitory factor seem to be new promising parameters for use in clinical routine. Pancreas specific scores (Imrie-Glasgow, pancreatitis outcome prediction) and scores assessing organ dysfunction (acute physiology and chronic health evaluation II, multiple organ dysfunction score, and Marshall score) remain of value in determining the severity, complications, and possible outcome of AP.

CONCLUSIONS

Indication, timing, and consequences of the methods applied need to be carefully considered and incorporated into clinical assessments. Currently, there is no single prognostic marker that would cover the whole range of problems associated with the treatment of AP. The prediction of severity and progression of AP can be achieved using a series of accurate methods. The decision to undertake interventional or surgical treatment is the most complex task requiring both clinical judgment and meticulous monitoring of the patient.

Predictors of severity and survival in acute pancreatitis: validation of the efficacy of early warning scores

OBJECTIVES

Early Warning Scores (EWS) is a widely used scoring system monitoring patient progress, which we have previously shown to predict outcome from acute pancreatitis. This study examined EWS from a larger group of patients to confirm if this predictive value held true.

METHODS

The EWS scores were compared with the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, modified organ dysfunction scores, Imrie scores, computed tomography grading scores, and Ranson criteria for 181 admissions with acute pancreatitis. The accuracy of EWS in predicting outcome was determined by receiver operator characteristics.

RESULTS

A total of 181 patients were identified with acute pancreatitis. On day 1 of admission, APACHE II scores were the most accurate predictor of mortality with an area under curve (AUC) values of 0.876, closely followed by EWS (AUC, 0.827). By day 2 and 3 after admission, the EWS was the most accurate predictor of mortality (AUC, 0.910 and 0.934, respectively). The APACHE II was the second most accurate scoring system at 48 and 72 hours (AUC, 0.892 and 0.911, respectively).

CONCLUSIONS

The EWSs on days 2 and 3 after admission are sensitive and specific in predicting mortality from acute pancreatitis. It is as accurate as the APACHE II scores and easier to implement in daily practice.

The Pancreatitis Outcome Prediction (POP) Score: a new prognostic index for patients with severe acute pancreatitis

OBJECTIVE

Severe acute pancreatitis, defined as pancreatitis with distant organ dysfunction, is a condition carrying a high mortality and morbidity. Current outcome prediction scores are based on small populations, usually from single specialist centers. Some scores cannot be applied until several days into hospital admission. We thus sought to develop a new and more sensitive outcome prediction score--the Pancreatitis Outcome Prediction (POP) Score--for these high-risk patients.

DESIGN

Retrospective cohort study of a large multicenter intensive care database.

SETTING

One hundred fifty-nine U.K. intensive care units.

PATIENTS

Participants were 2,462 patients admitted to intensive care units with severe acute pancreatitis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, physiologic, and biochemical data collected within the first 24 hrs of intensive care unit admission were used to develop a risk prediction score using logistic regression. The six variables with the strongest relationship to hospital outcome--arterial pH, age, serum urea, mean arterial pressure, PaO2/FIO2 ratio, and total serum calcium (in order of decreasing impact)--produced a model with a prognostic discrimination (area under the receiver operating characteristic curve = 0.838) superior to other models. These six factors were used to develop an objectively weighted multivariate prognostic score ranging from 0 to 40 points.

CONCLUSIONS

Prognostic stratification of patients with severe acute pancreatitis requiring intensive care offers a useful audit tool to gauge unit performance and improve delineation of subsets for prospective trials. Prospective validation of this new outcome prediction score is required, preferably in different countries. The validity of the POP Score for either hospital or intensive care admission could also be tested and assessed for superiority over existing scores.

Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors

INTRODUCTION

Acute pancreatitis (AP) is a rare complication after liver embolization (LE) of primary and secondary liver tumors (approximately 1.7%), but it has a significant morbidity and mortality potential if associated with other complications. It usually develops early within 24 h after the LE procedure.

STUDY PURPOSE

To calculate the frequency of AP after LE in our institution and to analyze the factors involved in this procedure (anatomical features, embolization materials, cytostatic drugs, technical factors).

MATERIALS AND METHODS

118 LE (bland embolization and transarterial chemoembolization) were performed in our institution. The study group included 59 patients who met the following inclusion criteria: one or more LE events, with complete pre- and post-interventional laboratory studies including: serum Ca(2+), creatinine, blood urea nitrogen, glucose, lactate dehydrogenase, aminotransferases, alkaline phosphatase, amylase, lipase, C-reactive protein, hematocrit and leukocytes. The diagnosis of AP was established according to the criteria of the Atlanta system of classification. For the statistical analysis the association between two response variables (e.g. AP after embolization and risk factor during the embolization, AP after embolization and volume of embolic material) was evaluated using Pearson's chi(2) test and Fisher's exact test.

RESULTS

The calculated frequency of AP after LE in our series was 15.2%. Amylase and lipase were elevated up to 8.7 and 20.1 times, respectively, 24 h after LE. We observed a statistically significantly lower incidence of AP in those patients who received 2 ml or less of embospheres compared with those with an embolization volume of >2 ml (Pearson's chi(2) = 4.5000, Pr = 0.034, Fisher's exact test = 0.040). Although carboplatin was administered to 7 of 9 of the patients who developed AP after the embolization procedure, there was no statistical significance (Fisher's exact test = 0.197) for carboplatin as an AP risk factor when compared with all the patients who received this drug (n = 107).

CONCLUSION

Although AP after LE seems to have a multifactorial etiology, both the toxicity of the antineoplastic drugs (carboplatin-related toxicity) as well as direct ischemic mechanisms (non-target embolization, reflux mechanisms) may be the most important causes of the inflammatory pancreatic reaction after LE. We suggest that systematic measurement of serum pancreatic enzymes should be performed in cases of abdominal pain following selective LE and transarterial chemoembolization in order to confirm acute pancreatitis after embolization, which can clinically mimic a postembolization syndrome.

Prognostic values of IL-6, IL-8, and IL-10 in acute pancreatitis

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.