Multivariate Model for the Prediction of Severity of Acute Pancreatitis in Children

Computed Tomography Assessment of Severity of Acute Pancreatitis in Bangladeshi Children

Purpose

Acute pancreatitis (AP) is common among children in Bangladesh. Its management depends mainly on risk stratification. This study aimed to assess the severity of pediatric AP using computed tomography (CT).

Methods

This cross-sectional, descriptive study was conducted in pediatric patients with AP at the Department of Pediatric Gastroenterology and Nutrition, BSMMU, Dhaka, Bangladesh.

Results

Altogether, 25 patients with AP were included, of whom 18 (mean age, 10.27±4.0 years) were diagnosed with mild AP, and 7 (mean age, 10.54±4.0 years) with severe AP. Abdominal pain was present in all the patients, and vomiting was present in 88% of the patients. Etiology was not determined. No significant differences in serum lipase, serum amylase, BUN, and CRP levels were observed between the mild and severe AP groups. Total and platelet counts as well as hemoglobin, hematocrit, serum creatinine, random blood sugar, and serum alanine aminotransferase levels (p>0.05) were significantly higher in the mild AP group than in the severe AP group (p=0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of CT severity index (CTSI) were 71.4%, 72.2%, 50%, and 86.7%, respectively. In addition, significant differences in pancreatic appearance and necrosis were observed between the two groups on CT.

Conclusion

CT can be used to assess the severity of AP. In the present study, the CTSI effectively assessed the severity of AP in pediatric patients.

Anemia can predict organ failure in acute pancreatitis

Acute pancreatitis (AP) is the leading hospital admission in Gastroenterology and has a variable clinical course. Identifying severity of AP patients in its early stages is of foremost importance to improve prognosis. The revised Atlanta Classification grades AP severity by the presence of organ failure and local complications.

A Retrospective Review of Children followed up with the Diagnosis of Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, the frequency of which increases in childhood.

AIM

To investigate the demographic, etiological, clinical, laboratory, and radiological characteristics of children followed up with the diagnosis of AP. The study also included genetic studies of recurrent cases.

MATERIALS AND METHODS

This retrospective cohort study included pediatric patients <18 years of age with AP who were followed up with recurrent pancreatitis in the Pediatrics Department of a University Hospital between January 2010 and April 2021. Patients who met at least 2 of the 3 criteria defined by the International Pediatric Pancreatitis Study Group (INSPPIRE) were accepted as AP. Demographic, etiological, and clinical data of the patients, developing complications, pathological evaluation of the samples, and genetic analysis results were obtained from the patient files. The obtained data were statistically analyzed using the SPSS version 26.0 program. Descriptive statistics of the data were expressed as mean ± standard deviation, median, minimum and maximum values, number (n), and percentage (%). Kolmogorov-Smirnov test, Mann Whitney U test, Chi-square test and Fischer test were used.

RESULTS

Fifty-four (50%) female and 54 (50%) male patients with a mean age of 9.96 ± 4.8 years who met the study criteria were included in the study. In the follow-up, it was reported that acute recurrent pancreatitis developed in 23 (21%) patients and chronic pancreatitis developed in 8 (7%) patients. The most common complaints were abdominal pain (94.4%), and vomiting (60.2%), followed by malnutrition (36.1%), nausea (17.6%), diarrhea (13%), and fever (13%). Etiology could not be determined in 19.4% of the patients. It was noted that the genetic predisposition of the patients played a role in the development of recurrent and chronic pancreatitis. Amylase, lipase, and CRP values, which are among the laboratory parameters showing the severity and prognosis of AP, were found to be significant.

CONCLUSIONS

Sociocultural and demographic data of the patients should also be taken into account. Gene sequences that cause to genetic predisposition should be determined in recurrent and chronic pancreatitis cases. Acute pancreatitis should be considered in the differential diagnosis of patients with frequent abdominal pain and vomiting.

Factors associated with hospital length of stay in children with acute pancreatitis

INTRODUCTION AND AIM

Acute pancreatitis (AP) is the most common cause of pancreatic disease in children. Previous studies have described factors related to days of hospital length of stay (LOS) in children. Our aim was to identify factors associated with LOS in AP.

MATERIALS AND METHODS

A retrospective study was conducted at the Hospital Infantil de México Federico Gómez in Mexico City, encompassing the time frame of January 1, 2017 and March 31, 2019. AP was confirmed by medical chart review, according to the INSPPIRE criteria at the time of hospital admission, in patients below 18 years of age. AP grade was classified, following the NASPGHAN guidelines. Demographic, clinical, biochemical, nutritional, and treatment data were collected. Prolonged hospital LOS was considered that which lasted 7 days or longer.

RESULTS

Fifty-one events (32 patients) were registered. Median LOS was 8 days (IQR 4-14 days). Antibiotic use was significantly associated with longer LOS (OR 31.71; 95% CI: 2.71-370.65; p = 0.006) and early feeding (EF) (within 72 h of admission) was associated with shorter LOS (OR 0.05; 95% CI: 0.001-0.63; p = 0.02). There was no association between LOS and the variables of age, recurrence, grade, etiology, comorbidities, complications, fluid resuscitation, parenteral nutrition, or biochemical characteristics upon admission.

CONCLUSION

Our study, like others, corroborated the fact that EF in the management of AP was associated with fewer days of hospital LOS.

The effect of anemia on the severity and prognosis of patients with acute pancreatitis: A single-center retrospective study

Anemia was a risk factor for a worse prognosis of many diseases. This study aims to investigate the relationship between anemia and the severity and prognosis of acute pancreatitis (AP). Inpatients hospitalized at the First Affiliated Hospital of Guangdong Pharmaceutical University with a primary diagnosis of AP between 1st July 2016 to 31st December 2020 were enrolled. Subsequently, disease severity, the incidence of complications, and the prognosis of patients with AP were compared between the anemic group and the non-anemic group. A total of 282 patients with acute pancreatitis were enrolled; 68.43% of them were also diagnosed with anemia. Notably, these patients had more severe disease (higher RANSON, acute physiologic assessment and chronic health evaluation-II, bedside index for severity in acute pancreatitis, and multiple organ dysfunction syndrome scores); higher incidence of organ failure (acute kidney injury [AKI] and acute heart failure); worse prognosis (higher incidence of vasoactive and diuretic agent use, longer hospital stays, and higher hospital costs) compared to that of patients without anemia (all P < .05). After adjusting for potential confounders, acute physiologic assessment and chronic health evaluation-II, bedside index for severity in acute pancreatitis, multiple organ dysfunction syndrome scores, hospital stay, and hospital costs in anemic patients were higher than those in non-anemic patients; besides, the incidence of AKI and using a diuretic agent in anemic patients was 6.645 and 4.053 times that of non-anemic patients in AP, respectively (all P < .05). Acute pancreatitis patients with anemia have more disease severity, higher incidence of AKI, and worse prognosis compared to those without anemia.

Admission risk factors and predictors of moderate or severe pediatric acute pancreatitis: A systematic review and meta-analysis

Introduction

Pediatric acute pancreatitis (PAP) has an increasing incidence and is now estimated to be almost as common as in adults. Up to 30% of patients with PAP will develop moderate or severe disease course (M/SPAP), characterized by organ failure, local or systemic complications. There is still no consensus regarding on-admission severity prediction in these patients. Our aim was to conduct a systematic review and meta-analysis of available predictive score systems and parameters, and differences between on-admission parameters in mild and M/SPAP.

Methods

We conducted a systematic search on the 14th February, 2022 in MEDLINE, Embase and CENTRAL. We performed random-effects meta-analysis of on-admission differences between mild and M/SPAP in laboratory parameters, etiology, demographic factors, etc. calculating risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) and created forest plots. For the meta-analysis of predictive score systems, we generated hierarchical summary receiver operating characteristic curves using a bivariate model. Chi-squared tests were performed and I2 values calculated to assess statistical heterogeneity.

Results

We included 44 studies - mostly retrospective cohorts - in our review. Among predictive score systems examined by at least 5 studies, the modified Glasgow scale had the highest specificity (91.5% for values ≥3), and the Pediatric Acute Pancreatitis Severity score the highest sensitivity (63.1% for values ≥3). The performance of other proposed score systems and values were summarized. Traumatic (RR: 1.70 95% CI: 1.09-2.67) and drug-induced (RR: 1.33 95% CI: 0.98-1.87) etiologies were associated with a higher rate of M/SPAP, while anatomical (RR: 0.6195% CI: 0.38-0.96) and biliary (RR: 0.72 95% CI: 0.53-0.99) PAP tended to be less severe.

Discussion

Many predictive score systems were proposed to assess the possibility of M/SPAP course. The most commonly used ones exhibit good specificity, but subpar sensitivity. Our systematic review provides a rigorous overview of predictive options assessed thus far, that can serve as a basis for future improvement of scores via the addition of parameters with a better observed sensitivity: e.g., lipase exceeding 7-times the upper threshold, hemoglobin, etc. The addition of etiological factors is another possibility, as they can herald a more severe disease course.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307271, PROSPERO, identifier: CRD42022307271.

The course of acute pancreatitis in children and potential simple laboratory markers of severity - a single centre retrospective study

AIM

To evaluate the usefulness of routinely measured biochemical and complete blood count parameters as potential markers of the severity of pediatric acute pancreatitis.

METHODS

The retrospective study included children with acute pancreatitis hospitalised over a 3-year period. Demographic, clinical and laboratory data were collected.

RESULTS

55 patients were enrolled in the study. Mild acute pancreatitis was diagnosed in 45 children (82%), moderately severe in 7 (13%), and severe in 3 patients (5%). Together 10 children (18%) were categorized into a single severe group. Children with severe acute pancreatitis had higher white blood cell and platelet counts on admission as well as a C-reactive protein concentration after 48 hours. The C-reactive protein concentration after 48 hours (cut-off: 127,2 mg/l) and the white blood cell count on admission (cut-off: 13,5x10³ /μl) were found to be statistically significant markers in predicting the severity of the disease. The C-reactive protein concentration after 48 hours was demonstrated as an independent predictor.

CONCLUSION

Severe acute pancreatitis is observed in a quite significant percentage of children. The white blood cell count on admission and the C-reactive protein concentration after 48 hours (as an independent predictor) may be potential simple laboratory markers of the severity of the disease.

Etiology, case fatality, recurrence, and severity in pediatric acute pancreatitis: a meta-analysis of 48 studies

For children, there are very few published reviews focusing on severe acute pancreatitis (AP). PubMed, EMBASE, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Wanfang data, EBSCO, and Cochrane Library were searched from inception until March 2020. Meta-regression analyses were used to estimate the etiology, case fatality, recurrence, and severity of pediatric AP in different regions (North America, Asia, South America, Europe, and Oceania). Pooled data from 47 papers (48 studies) found that main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate (CFR) of pediatric AP is 4.7% (North America), 6.2% (Europe), 2.4% (Asia), 3.1% (South America), and 7.4% (Oceania). The incidence rates of recurrent acute pancreatitis (RAP) in children who have had an episode of acute pancreatitis in North American, Asia, and Europe were 15.3, 13.1, and 13.8%, respectively. The incidence of severe acute pancreatitis (SAP) in different regions was 30.3% (Oceania), 29.2% (South America), 20.8% (Europe), 15.8% (Asia), and 13.7% (North America). It suggests that physicians should notice the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage. IMPACT: It indicates the etiology of pediatric acute pancreatitis for the initial assessment, diagnosis, and prediction of relapse. Main causes of pediatric AP were gallstones in Asia; trauma in Oceania; and idiopathic in Europe, North America, and South America. The case-fatality rate of pediatric AP is diverse worldwide. It suggests that physicians noticed the etiology of pediatric AP for the initial assessment, diagnosis, prediction of relapse, and appropriate treatment at a later stage.

Who's at Risk? A Prognostic Model for Severity Prediction in Pediatric Acute Pancreatitis

OBJECTIVES

The aim of the study was to validate and optimize a severity prediction model for acute pancreatitis (AP) and to examine blood urea nitrogen (BUN) level changes from admission as a severity predictor.

STUDY DESIGN

Patients from 2 hospitals were included for the validation model (Children's Hospital of the King's Daughters and Children's National Hospital). Children's Hospital of the King's Daughters and Cincinnati Children's Hospital Medical Center data were used for analysis of BUN at 24 to 48 hours.

RESULTS

The validation cohort included 73 patients; 22 (30%) with either severe or moderately severe AP, combined into the all severe AP (SAP) group. Patients with SAP had higher BUN (P = 0.002) and lower albumin (P = 0.005). Admission BUN was confirmed as a significant predictor (P = 0.005) of SAP (area under the receiver operating characteristic [AUROC] 0.73, 95% confidence interval [CI] 0.60-0.86). Combining BUN (P = 0.005) and albumin (P = 0.004) resulted in better prediction for SAP (AUROC 0.83, 95% CI 0.72-0.94). A total of 176 AP patients were analyzed at 24-48 hours; 39 (22%) met criteria for SAP. Patients who developed SAP had a significantly higher BUN (P < 0.001) after 24 hours. Elevated BUN levels within 24 to 48 hours were independently predictive of developing SAP (AUROC: 0.76, 95% CI: 0.66-0.85). Patients who developed SAP had a significantly smaller percentage decrease in BUN from admission to 24 to 48 hours (P = 0.002).

CONCLUSION

We externally validated the prior model with admission BUN levels and further optimized it by incorporating albumin. We also found that persistent elevation of BUN is associated with development of SAP. Our model can be used to risk stratify patients with AP on admission and again at 24 to 48 hours.

Young Age Predicts Acute Pancreatitis Severity in Children

OBJECTIVES

The course and evolution of pediatric acute pancreatitis (AP) is poorly understood. Prognostication models in children perform poorly and lack consensus. We aimed to identify predictors of AP severity, and the risk for AP recurrence.

METHODS

We retrospectively studied all patients hospitalized with AP at a single tertiary center, between January 1995 and June 2016. Patient demographics and admission laboratory data were assessed for severity and recurrence prediction.

RESULTS

A total of 68 patients accounting for a total of 117 (15 moderate-severe) AP episodes were reviewed. Patients with moderate-severe disease were significantly younger (median [interquartile range (IQR)] of 8.3 [4.0-14.4] vs 13.8 [8.1-16.0] years, P = 0.02). Young age at presentation was associated with odds ratio of 3.8 (confidence interval [CI] 1.2-12.1) for children younger than 12 years and 5.8 (CI 1.6-21.4) for children younger than 6 years for developing moderate-severe disease.Further subanalysis of the 59 patients with first-time AP episodes, demonstrated younger age (median [IQR] of 5.3 [2.9-10.4] vs 12.0 [6.3-15.8] years, P = 0.03) and elevated white blood cell count (median [IQR] of 22.8 [11.8-31.3] vs 11.0 [8.1-14.6] 10/L, P < 0.01) of patients with moderate-severe disease, conferring a risk for moderate-severe disease with odds ratio of 7.5 (CI 1.5-38.2) for children younger than 6 years and 5.3 (CI 1.1-25.4) for patients with white blood cell count >15 × 10/L, respectively. Fourteen (23.7%) of 59 patients with first-time episodes had recurrent AP. Analysis of the data at the primary episode failed to identify predictors to indicate future recurrence.

CONCLUSIONS

In our cohort, only young age (<12 years) predicted AP severity. No parameters were identified to predict future development of AP recurrence.

Validation of Lipase and Systemic Inflammatory Response Syndrome as Prognostic Indicators in Pediatric Acute Pancreatitis: A Retrospective Analysis

INTRODUCTION

Acute pancreatitis (AP) is understudied in the pediatric population despite increasing incidence. Although many cases are mild and resolve with supportive care, severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. There is a lack of pediatric-specific predictive tools to help stratify risk of SAP in children.

METHODS

A retrospective cohort study of patients with AP or recurrent AP at Cohen Children's Medical Center between 2011 and 2016 was performed. Lipase level and the presence of pediatric systemic inflammatory response syndrome (SIRS) on admission were examined as potential predictors of SAP and length of stay (LOS). A multivariate logistic regression or analysis of covariance was used to conduct the multivariate analysis.

RESULTS

Seventy-nine pediatric patients met inclusion criteria. Approximately 37% (29/79) had SIRS on admission, 22% (17/79) developed SAP, and there were no mortalities. In both the univariate and multivariate models, SIRS was a predictor of SAP. Mean (SD) LOS for patients with SIRS compared with without SIRS was 9.6 ± 8.3 compared with 6.3 ± 6.9 days (P < 0.05). The mean LOS of patients with one or more comorbidity (48%, 38/79) was 10.0 ± 9.5 compared with 5.2 ± 4.0 days (P < 0.01) for those patients without any comorbidities. Only the presence of comorbidities predicted length of time spent nil per os (NPO; P = 0.0022). Patients with comorbidities stayed an average of 5.6 ± 7.6 days NPO, whereas those without comorbidities spent 2.8 ± 2.4 days NPO. Lipase was not predictive of SAP, LOS, or length of time spent NPO.

CONCLUSIONS

These results support the use of SIRS as a simple screening tool on admission to identify children at risk for the development of SAP. The presence of any comorbidity was predictive of LOS and length of NPO in the multivariate model. This may reflect that comorbidities prolong pancreatitis or influence disposition planning.