Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early Predictive Value of Different Indicators for Persistent Organ Failure in Acute Pancreatitis: A Systematic Review and Network Meta-Analysis

GOALS

In this study, we conducted this network meta-analysis (based on the ANOVA model) to evaluate the predictive efficacy of each early predictor.

BACKGROUND

Persistent organ failure (POF) is one of the determining factors in patients with acute pancreatitis (AP); however, the diagnosis of POF has a long-time lag (>48 h). It is of great clinical significance for the early noninvasive prediction of POF.

STUDY

We conducted a comprehensive and systematic search in PubMed, Cochrane library, Embase, and Web of Science to identify relevant clinical trials, case-control studies, or cohort studies, extracted the early indicators of POF in studies, and summarized the predictive efficacy of each indicator through network meta-analysis. The diagnostic odds ratio (DOR) was used to rank the prediction efficiency of each indicator.

RESULTS

We identified 23 studies in this network meta-analysis, including 10,393 patients with AP, of which 2014 patients had POF. A total of 10 early prediction indicators were extracted. The mean and 95% CI lower limit of each predictive indicator were greater than 1.0. Albumin had the largest diagnostic odds ratio, followed by high-density lipoprotein-cholesterol (HDL-C), Ranson Score, beside index for severity in acute pancreatitis Score, acute physiology and chronic health evaluation II, C-reactive protein (CRP), Interleukin 6 (IL-6), Interleukin 8 (IL-8), Systemic Inflammatory Response Syndrome (SIRS) and blood urea nitrogen.

CONCLUSIONS

Albumin, high-density lipoprotein-cholesterol, Ranson Score, and beside index for severity in acute pancreatitis Score are effective in the early prediction of POF in patients with AP, which can provide evidence for developing effective prediction systems. However, due to the limitations of the extraction method of predictive indicators in this study, some effective indicators may not be included in this meta-analysis.

CT Features of Recurrent Acute Pancreatitis: Early Phase Versus Late Phase

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.

Safety of early same-admission laparoscopic cholecystectomy for acute mild biliary pancreatitis. A retrospective study for acute pancreatitis

INTRODUCTION

As the standard procedure for the surgical treatment for gallbladder stones, we investigated the controversy surrounding the optimal time for laparoscopic cholecystectomy (LC) for acute mild biliary pancreatitis (AMBP).

AIM

To further address the optimal timing of LC, we conducted a retrospective study comparing early (< 72 h, group I) with delayed (> 72 h, group II) LC for AMBP during the same admission.

MATERIAL AND METHODS

This retrospective study included medical records of all patients who were admitted with a diagnosis of acute mild biliary pancreatitis at Dongyang People's Hospital from July 2011 to June 2019.

RESULTS

A total of 119 patients were divided into an early LC group (group I; 52 patients) and a control group (group II; 67 patients). Conversion to open cholecystectomy (COC) was performed in 17 patients (6 patients in group I and 11 patients in group II, p = 0.62). There were no significant differences in terms of estimated blood loss and duration of surgery (p = 0.08 and p = 0.64, respectively). The overall hospital stay in group I was significantly shorter than in group II (10.86 ±3.21 vs. 13.29 ±4.51 days, p = 0.001). Compared with postoperative bile leakage (p = 0.72) and postoperative morbidity (p = 0.97) and mortality, there were no significant differences between the groups.

CONCLUSIONS

Early LC during the same admission is safe for acute mild biliary pancreatitis and has the advantage of shortening overall hospital stay. There was no significant increase in COC, bile duct injury, and complications.

MR Imaging for Early Extrapancreatic Necrosis in Acute Pancreatitis

RATIONALE AND OBJECTIVES

To study the MRI characteristics of early extrapancreatic necrosis and compare them with those of peripancreatic fluid collections in acute pancreatitis (AP).

MATERIALS AND METHODS

This retrospective study enrolled 70 AP patients who had extrapancreatic collections visible on MRI within 1 week of onset. Extrapancreatic collections were divided into extrapancreatic necrosis and peripancreatic fluid collections based on follow-up MRI, CT, or pathology. The number and area of extrapancreatic collections, extrapancreatic inflammation on MRI (EPIM) score, MR severity index score and clinical characteristics were evaluated and compared between the two groups.

RESULTS

Of the seventy AP patients, 32 (45.7%) had extrapancreatic necrosis, and 38 (54.3%) had peripancreatic fluid collections. The number and area of extrapancreatic collections, MR severity index score, EPIM score, and prevalence of associated hemorrhage were significantly higher in extrapancreatic necrosis patients than in those with peripancreatic fluid collections (p < 0.001). Among the single indicators, the accuracy of the area of extrapancreatic collections (AUC = 0.871) was comparable to that of the EPIM score for predicting extrapancreatic necrosis and was significantly higher than that of the other two indicators. The combination of all indicators showed the highest predictive accuracy (AUC = 0.949), and combinations of two or more indicators demonstrated significantly higher predictive accuracy for extrapancreatic necrosis than any single indicator (p < 0.05) except for the area of extrapancreatic collections (p > 0.05).

CONCLUSION

The MRI characteristics have the potential to differentiate early extrapancreatic necrosis from peripancreatic fluid collections and help indicate extrapancreatic necrosis.

Ranson score to stratify severity in Acute Pancreatitis remains valid - Old is gold

Introduction: Acute pancreatitis (AP) is a common gastrointestinal disease with a wide spectrum of severity and morbidity. Developed in 1974, the Ranson score was the first scoring system to prognosticate AP. Over the past decades, while the Ranson score remains widely used, it was identified to have certain limitations, such as having low predictive power. It has also been criticized for its 48-hour requirement for computation of the final score, which has been argued to potentially delay management. With advancements in our understanding of AP, is the Ranson score still relevant as an effective prognostication system for AP?Areas covered: This review summarizes the available evidence comparing Ranson score with other conventional and novel scoring systems, in terms of prognostic accuracy, benefits, limitations and clinical applicability. It also evaluates the effectiveness of Ranson score with regard to the Revised Atlanta Classification.Expert opinion: The Ranson score consistently exhibits comparable prognostic accuracy to other newer scoring systems, and the 48-hour timeframe for computing the full Ranson score is an inherent strength, not a weakness. These aspects, coupled with relative ease of use, practicality and universality of the score, advocate for the continued relevance of the Ranson score in modern clinical practice.

THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION

BACKGROUND

New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012.

OBJECTIVE

The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices.

METHODS

A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study.

RESULTS

Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification.

CONCLUSION

Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

Potential role of imaging for assessing acute pancreatitis-induced acute kidney injury

Acute kidney injury (AKI) is a common complication of acute pancreatitis (AP) that is associated with increased mortality. Conventional assessment of AKI is based on changes in serum creatinine concentration and urinary output. However, these examinations have limited accuracy and sensitivity for the diagnosis of early-stage AKI. This review summarizes current evidence on the use of advanced imaging approaches and artificial intelligence (AI) for the early prediction and diagnosis of AKI in patients with AP. CT scores, CT post-processing technology, Doppler ultrasound, and AI technology provide increasingly valuable information for the diagnosis of AP-induced AKI. Magnetic resonance imaging (MRI) also has potential for the evaluation of AP-induced AKI. For the accurate diagnosis of early-stage AP-induced AKI, more studies are needed that use these new techniques and that use AI in combination with advanced imaging technologies.

Importance of CT-scan predicting clinical outcomes in gastro-intestinal perforation

Background

Gastrointestinal (GI) perforations are an acute surgical dilemma, with diagnostic workup often requiring abdominal imaging. Post-operative care for these patients may vary and oftentimes includes ICU care for sepsis, but not always. We evaluated if free fluid and air on computed tomography (CT) could be associated with sepsis, septic shock and mortality in GI perforations. The aim of our study was a correlation between a new CT-scan scoring system and septic complications in GI perforations.

Methods

We conducted an observational retrospective study about patients who underwent emergency surgery for intestinal perforation between January 2014 and June 2017. Inclusion criteria were a CT-scan positive for free fluid and air, and an intestinal perforation confirmed intraoperatively. A CT-score was created to evaluate location and extent of free fluid and air related to clinical outcome and prognosis. Univariate analysis between the CT score and the various clinical outcomes was conducted with the non-parametric Mann-Whitney test for continuous variables and with the chi-square test for categorical variables.

Results

One-hundred and fifty-one patients were evaluated. The mortality was 23.18% and the complications were present in 45.95%. The median CT score for patients who developed complications was 3, compared with a value of 2 in the absence of complications (P=0.008). A CT score of 4 or greater had a sensitivity and specificity for predicting pre-operative sepsis of 73.33% and 64.42% respectively, and for pre-operative septic shock of 35.56% and 93.27%. Looking at post-operative sepsis, sensitivity and specificity were 57.45% and 70.19%, and for septic shock 36.17% and 85.85%. Spearman correlation analysis revealed that at higher scores at CT score corresponded higher scores at the P-POSSUM morbidity, P-POSSUM mortality and WSES Sepsis Severity Score.

Conclusions

Our CT score shows a significant correlation with validated predictive scoring systems with regards to predicting sepsis, septic shock and complications—and seems to be a useful outcome predictor in GI perforation.

Comparison of radiological scoring systems, clinical scores, neutrophil-lymphocyte ratio and serum C-reactive protein level for severity and mortality in acute pancreatitis

Comparison of radiological scoring systems, clinical scores, neutrophil-lymphocyte ratio and serum C-reactive protein level for severity and mortality in acute pancreatitis BACKGROUND/AIMS To compare radiological scoring systems, clinical scores, serum C-reactive protein (CRP) levels and the neutrophil-lymphocyte ratio (NLR) for predicting the severity and mortality of acute pancreatitis (AP). MATERIALS AND METHODS Demographic, clinical, and radiographic data from 80 patients with AP were retrospectively evaluated. The harmless acute pancreatitis score (HAPS), systemic inflammatory response syndrome (SIRS), bedside index for severity in acute pancreatitis (BISAP), Ranson score, Balthazar score, modified computed tomography severity index (CTSI), extrapancreatic inflammation on computed tomography (EPIC) score and renal rim grade were recorded. The prognostic performance of radiological and clinical scoring systems, NLR at admission, and serum CRP levels at 48 hours were compared for severity and mortality according to the revised Atlanta Criteria. The data were evaluated by calculating the receiver operator characteristic (ROC) curves and area under the ROC (AUROC). RESULTS Out of 80 patients, 19 (23.8%) had severe AP, and 9 (11.3%) died. The AUROC for the BISAP score was 0.836 (95%CI: 0.735-0.937), with the highest value for severity. With a cut-off of BISAP ≥2, sensitivity and specificity were 68.4% and 78.7%, respectively. The AUROC for NLR was 0.915 (95%CI: 0.790-1), with the highest value for mortality. With a cut-off of NLR >11.91, sensitivity and specificity were 76.5% and 94.1%, respectively. Of all the radiological scoring systems, the EPIC score had the highest AUROC, i.e., 0.773 (95%CI: 0.645-0.900) for severity and 0.851 (95%CI: 0.718-0.983) for mortality, with a cut-off value ≥6. CONCLUSION The BISAP score and NLR might be preferred as early determinants of severity and mortality in AP. The EPIC score might be suggested from the current radiological scoring systems.

Chest computed tomography semi-quantitative pleural effusion and pulmonary consolidation are early predictors of acute pancreatitis severity

Background

To study the predictive value of semi-quantitative pleural effusion and pulmonary consolidation for acute pancreatitis (AP) severity.

Methods

Thorax-abdominal computed tomography (CT) examinations were performed on 309 consecutive AP patients in a single center. Among them, 196 were male, and 113 were female, and the average age was 50±16 years. The etiology of AP was biliary in 43.7% (n=135), hyperlipidemia in 22.0% (n=68), alcoholic in 7.4% (n=23), trauma in 0.6% (n=2), and postoperative status in 1.6% (n=5) cases; 24.6% (n=76) of patients did not have specified etiologies. The prevalence of pleural effusion and pulmonary consolidation was noted. The pleural effusion volume was quantitatively derived from a CT volume evaluation software tool. The pulmonary consolidation score was based on the number of lobes involved in AP. Each patient's CT severity index (CTSI), acute physiology and chronic health evaluation II (APACHE II) scoring system, and bedside index for severity in acute pancreatitis (BISAP) scores were obtained. The semi-quantitative pleural effusion and pulmonary consolidation were compared to these scores and clinical outcomes by receiver operator characteristic (ROC) curve and area under the curve (AUC) analysis.

Results

In the 309 patients, 39.8% had pleural effusion, and 47.9% had pulmonary consolidation. The mean pleural effusion volume was 41.7±38.0 mL. The mean pulmonary consolidation score was 1.0±1.2 points. The mean CTSI was 3.7±1.8 points, the mean APACHE II score was 5.8±5.1 points, and the mean BISAP score was 1.3±1.0 points; 5.5% of patients developed severe AP, and 13.9% of patients developed organ failure. Pleural effusion volume and pulmonary consolidation scores correlated to the scores for the severity of AP. In predicting severe AP, the accuracy (AUC 0.839) of pleural effusion volume was similar to that of the CTSI score (P=0.961), APACHE II score (P=0.757), and BISAP score (P=0.906). The accuracy (AUC 0.805) of the pulmonary consolidation score was also similar to that of the CTSI score (P=0.503), APACHE II score (P=0.343), and BISAP score (P=0.669). In predicting organ failure, the accuracy (AUC 0.783) of pleural effusion volume was similar to that of the CTSI score (P=0.473), APACHE II score (P=0.119), and BISAP score (P=0.980), and the accuracy (AUC 0.808) of the pulmonary consolidation score was also similar to that of the CTSI score (P=0.236), APACHE II score (P=0.293), and BISAP score (P=0.612).

Conclusions

Pleural effusion and pulmonary consolidation are common in AP and correlated to the severity of AP. Furthermore, the pleural effusion volume and pulmonary consolidation lobes can provide early prediction of severe AP and organ failure.

Extrapancreatic Inflammation on Magnetic Resonance Imaging for the Early Prediction of Acute Pancreatitis Severity

OBJECTIVES

This work aimed to study the early predictive value of extrapancreatic inflammation on magnetic resonance imaging (EPIM) for acute pancreatitis (AP) severity.

METHODS

The EPIM score, magnetic resonance severity index, Acute Physiology and Chronic Health Evaluation (APACHE II) score, bedside index of severity in AP, and high-sensitivity C-reactive protein levels were evaluated for 337 AP patients. The extrapancreatic inflammation on computed tomography (EPIC) was also assessed for 86 patients undergoing computed tomography. The predictive values of these scores for severe AP and organ failure were evaluated using receiver operating characteristic curve analyses.

RESULTS

Of the 337 AP patients, 55 (16.3%) had organ failure and 17 (5.0%) had severe AP. The EPIM showed a strong correlation with the EPIC (r = 0.794, P < 0.001) and had a higher correlation with the APACHE II and hospital stay compared with the EPIC. The accuracy of the EPIM in predicting severe AP and organ failure (areas under the curve, 0.844 and 0.817) was consistent with that of the APACHE II and bedside index of severity in AP, and higher than that of the magnetic resonance severity index.

CONCLUSION

The EPIM is more helpful in assessing AP severity than the EPIC and can indicate the occurrence of severe AP and organ failure early.

E and P Selectins as Potential Markers in the Assessment of the Severity of Acute Pancreatitis

OBJECTIVES

Acute pancreatitis (AP) is commonly associated with the release of adhesion molecules such as E and P selectins. We designed the present study to evaluate the role of selectins as potential markers that could reflect the severity of the disease.

METHODS

One hundred fifty patients with AP constituted the patient group, whereas 70 healthy volunteers established the control group. In both groups, blood samples were taken for measurements of E selectin, P selectin, caspase-cleaved cytokeratin 18, and total soluble cytokeratin 18 levels on admission and days 1, 2, 4, and 6.

RESULTS

Values of E and P selectins on admission were both elevated compared with control subjects (P < 0.01). The nonsurvivors had higher values of E selectin (P < 0.04) and P selectin (P < 0.03) on admission. Levels of E and P selectin showed positive correlation with the length of stay (P < 0.05). E selectin on admission yielded a sensitivity of 75% and 78% specificity, whereas P selectin had a sensitivity of 67% and 91% specificity.

CONCLUSIONS

Selectin values in the early course of AP may play a role as indicators of overall prognosis, which may help physicians in better understanding the pathophysiology of a benign disease that may have serious and detrimental complications.

The Value of Modified Renal Rim Grade in Predicting Acute Kidney Injury Following Severe Acute Pancreatitis

OBJECTIVE

To retrospectively determine the value of modified renal rim grade (MRRG) in predicting acute kidney injury (AKI) in the early phase of severe acute pancreatitis (SAP).

METHODS

This institutional review board-approved retrospective study included patients with SAP who underwent abdominal contrast-enhanced computed tomography (CT) within 48 hours after disease onset. Modified renal rim grade, renal rim grade, CT severity index, modified CT severity index, extrapancreatic inflammation on CT scores, and posterior pararenal (PPR) space involvement were assessed. Clinical data, including bedside index of severity in acute pancreatitis and New Japanese Severity Scoring system scores, were collected. Primary end points were AKI and mortality. Scores were evaluated by receiver operating characteristic curve analysis. Correlational analyses between MRRG scores and the other scores were performed with Spearman analysis.

RESULT

One hundred five consecutive patients were enrolled in our study. The areas under the curve (AUCs) of MRRG in predicting AKI (0.90) and mortality (0.83) were comparable to extrapancreatic inflammation on CT (0.89 and 0.85, P > 0.05) and were higher than those of the other CT scores (P < 0.05). Modified renal rim grade score of greater than 4 yielded sensitivities and specificities of 81% and 89% for predicting AKI and 88% and 66% for mortality. Modified renal rim grade correlated moderately with bedside index of severity in acute pancreatitis (Spearman r = 0.47) and New Japanese Severity Scoring system (r = 0.43) scores. Besides, the prevalence of PPR space involvement in nonrecovery AKI patients was higher than that in recovery patients (94% vs 36%, P < 0.05).

CONCLUSIONS

Modified renal rim grade is well correlated with the occurrence of AKI and mortality in SAP. The PPR space involvement is a promising prognostic factor for nonrecovery of AKI in SAP patients.