Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit

Nurse-Led Care at Home Visit Versus Standard Care in Patients with Mild Acute Pancreatitis: A Retrospective Analysis

BACKGROUNDS

Frequent hospitalization and the costs of hospitalization are the main burdens in China for patients with acute pancreatitis. Most admitted patients have mild disease conditions that do not require hospitalization.

AIMS

Here, we compare some health and economic aspects of patients with mild acute pancreatitis who received nurse-led care at home visits against those who were hospitalized on follow-up.

METHODS

Patients discharged from the hospital after treatment for mild acute pancreatitis received (NC cohort, n = 104) or did not receive (HN cohort, n = 141) regular home visits by nurses for treatment and care. Patients were rehospitalized by caregivers with or without help of nurse.

RESULTS

Hospital readmission events occurred in both cohorts at a follow-up care time of 2 months. Compared with the time of discharge from the hospital, unwanted effects were higher in follow-up care in all patients (p < 0.001 for all). Patients in the NC cohort had less time to resolution of pain, less time to resumption of oral solid food intake, smaller number of patients with hospital readmissions, less average time of hospitalization, lower cost of care, and lower occurrence of unwanted effects than those of patients in the HN cohort during 2 months of follow-up care (p < 0.05 for all).

CONCLUSIONS

Patients with mild acute pancreatitis who undergo treatment require nurse-led nontreatment intervention(s) for rehabilitation in follow-up. Nurse-led follow-up care at-home visits increase recovery, are beneficial and cost-effective, and decrease unwanted adverse effects in patients receiving treatment for mild acute pancreatitis.

LEVEL OF EVIDENCE

IV.

TECHNICAL EFFICACY

Stage 5.

Acute peripancreatic fluid collection in acute pancreatitis: Incidence, outcome, and association with inflammatory markers

Background

The hospital outcomes and predictors of acute peripancreatic fluid collection (APFC) have not been well-characterized. In this study, we aimed to investigate the clinical outcomes of APFC in patients with acute pancreatitis (AP) and the role of the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and C-reactive protein (CRP) level in predicting the occurrence of APFC.

Methods

In this retrospective study, the complicated group (patients with APFC) and the uncomplicated group (patients without APFC) were compared for their clinical characteristics, hospital outcomes (mortality rate, intensive care unit admission rate, and length of hospital stay), pseudocyst formation, CRP levels, SII, and SIRI on admission and at 48 hours.

Results

Of 132 patients with AP, 51 (38.6%) had APFC and eight (6.1%) had pancreatic pseudocysts. Of 51 patients with APFC, 15.7% had pancreatic pseudocysts. Pseudocyst did not develop in the uncomplicated group. SII value at 48 h [median 859 (541-1740) x 109/L vs. 610 (343-1259) x 109/L, P = 0.01] and CRP level at 48 h [89 (40-237) mg/L vs. 38 (12-122) mg/L, P = 0.01] were higher in the complicated group than in the uncomplicated group. The length of hospital stay was longer in the complicated group, compared with the uncomplicated group [median 8 days (5-15), vs. 4 days (3-7), P < 0.001, respectively]. No significant difference was detected between the two study groups' mortality rates and intensive care unit admission rates.

Conclusions

While 38.6% of the AP patients had APFC, 6.1% of all patients and 15.7% of the patients with APFC had pancreatic pseudocysts. APFC was found to lengthen the hospital stay and to be associated with the SII value and CRP level measured at 48 h.

The Potential Role of Model for End-Stage Liver Disease (MELD)-Sodium Score in Predicting the Severity of Acute Pancreatitis

Background and aim Acute pancreatitis is a common inflammation of the pancreas which can be severe and even potentially mortal. High rates of mortality showed the importance of immediate identification of patients at high risk and led the clinicians to refer to various scoring systems. Our aim was to investigate a clinical predictive model using the Model for End-Stage Liver Disease-Sodium (MELD-sodium) scoring system, adapting it to acute pancreatitis patients referring to the systemic inflammatory nature of the disease and potential multi-organ failures in severe form. Methods Our multicenter study was designed retrospectively. The medical records were reviewed for the period of two years. Demographics, biochemical results, MELD-sodium scores and mortality rates were analysed. Results MELD-sodium score was found to be statistically correlated with both mortality and the severity of pancreatitis (p<0.001) and significant difference between both mild and severe (p<0.001), moderate and severe groups (p<0.001). Mortality was found to be significantly higher in patients with MELD-Na score when the cut-off value was accepted as '≥11'. Conclusion We found that MELD-sodium score was significantly associated with both severity of disease and mortality rates and also significantly effective between both mild/severe and moderate/severe groups which may be a guide for future multi-center reviews with larger patient and control groups, which can define the potential role of this non-invasive and easy-to-use predictive model in acute pancreatitis patients.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Is there a correlation between the initial calcium level and Balthazar classification in patients with acute pancreatitis?

BACKGROUND

While a life-threatening course is observed in 2-3% of patients with acute pancreatitis (AP), mortality can be up to 50% in severe AP. In our study, we research relationship between calcium level and Modified Balthazar (MB) score.

METHODS

354 patients who were followed up with a diagnosis of AP between 2013 and 2019 were included in our study. Serum calcium level was measured within the first 24 h. Abdominal computed tomography (CT) was performed in all patients in the first 12 h and between 3 and 7 days. The severity of AP was determined according to the MB classification. The correlation between calcium level and MB classification was examined.

RESULTS

206 (58.2%) of the patients were women. Mean age was 54.8±17.9 years (range: 18-100). It was observed that the rate of severe AP was significantly higher in the low calcium group compared to the MB classification in which tomographies taken at ad-mission and 72 h after were evaluated (p<0.05). Furthermore, progression was higher in low calcium group (p<0.05). The cutoff value was 9.35 mg/dl for the ROC analysis performed to distinguish mild pancreatitis from moderate-severe pancreatitis according to the MB classification performed by CT obtained after 72 h based on the Ca values. For the cutoff value of 9.35 mg/dl (AUC: 0.581, p=0.018, 95% Cl: 0.514-0.649), the sensitivity was 57.4% and the specificity was 53.1%.

CONCLUSION

Since there is a correlation between the initial calcium level and the severity of the disease according to the CT-scan obtained later, the calcium level gives us an idea of the course of the disease.

The harmless acute pancreatitis score (HAPS) identifies non-severe patients: A systematic review and meta-analysis

INTRODUCTION

We previously described a scoring system to identify patients with harmless acute pancreatitis as defined by absence of pancreatic necrosis, no need for artificial ventilation or dialysis, and non-fatal course. This scoring system, the Harmless Acute Pancreatitis Score (HAPS), can be quickly calculated from three parameters: absence of abdominal tenderness or rebound, normal hematocrit and normal creatinine level. We aim to assess the positive predictive value (PPV) of the HAPS by performing a meta-analysis of subsequently published studies.

METHODS

We performed a literature search using Pubmed, Web of Science^TM and Google Scholar. We used random effects models, with maximum likelihood estimates, to estimate the PPV of HAPS. We produced forest plots and used the I² statistic to quantify heterogeneity.

RESULTS

Twenty reports covering 6374 patients were identified. The overall PPV based on 16 studies that closely followed the original description of the HAPS system was 97% (95%CI 95-99%) with significant heterogeneity (I² = 76%; P < 0.01). For 11 studies in which HAPS was used to identify patients with mild AP, the overall PPV dropped to 83% (74-91%). For 8 studies in which HAPS was used to predict non-fatal course the overall PPV was 98% (97-100%).

CONCLUSION

The HAPS, if used as originally defined, accurately identifies patients with non-severe AP who will not require ICU care and facilitate selection of patients who can be discharged after a short stay on a general ward or can even be cared for at home. This could free hospital beds for other purposes and decrease healthcare costs.

C-Reactive Protein as a Predictor of Complicated Acute Pancreatitis: Reality or a Myth?

Introduction C-reactive protein (CRP) has been reported as a predictor of the severity of acute pancreatitis (AP). However, there is conflicting evidence in the literature. The proposed cut-off values and intervals for best prediction include an absolute value of 150 at 48 hours; an absolute value of 190 at 48 hours; and the interval change in CRP of 90 at 48 hours. The current study assesses the value of CRP at different intervals and cut-offs in predicting complicated acute pancreatitis (CAP) and compares its performance against other available predictors like neutrophil to lymphocyte ratio (NLR); Glasgow scoring system and modified CT severity index (MCTSI).  Methods Analysis of prospectively maintained data for index episodes of acute pancreatitis managed in 225 patients over a period of five years (2014-2018) was done. CAP was defined by using revised Atlanta classification and included all the AP patients with local and or systemic complications. It was used as a gold standard. Diagnostic and predictive performance of different biochemical markers and multifactorial scoring systems were determined by analyzing receiving operating curves (ROCs), the area under the curve (AUC), sensitivity, specificity, and predictive values (positive and negative).  Results Out of 225 patients, 122 were female while 103 patients were male. CAP developed in 47 patients (20.9%) while 178 (79.1%) patients had mild AP. Overall, in-hospital mortality rate was 1.8% (n=4). ROC analysis demonstrated that CRP at admission had low discriminatory value (AUC= 0.54, p-value=0.74). CRP at 48 hours had AUC of 0.70 (p-value=0.007). At a cut-off of 150, the positive predictive value (PPV) of 150 was 30 %. The PPV of CRP at 48 hours at a cut-off of 190 was 28%. Interval change in CRP at 48 hours greater than 90 had a PPV of 26 %. Further comparison of CRP with other scoring systems like Glasgow scoring system (AUC= 0.65), NL ratio (AUC=0.54), and MCTSI was performed. Among the single predictors, although, NL ratio showed good sensitivity at a cut-off value of 4.7 (87.23%), however, its discriminatory power was negligible (AUC=0.542, p-value=0.513). The overall best performance was achieved by the MCTSI scoring system at a cut-off of 3 (AUC=0.90, sensitivity=83.33 %, specificity=100%, diagnostic accuracy=94.49%).  Conclusion CRP measured at admission or at 48 hours has a very limited role in the prediction of CAP. Along with other scoring systems, its negative predictive value should be used to predict cases with mild AP which can help in clinical decision making for early discharge or management of such patients on ambulatory care basis. MCTSI scoring system can be used in cases with high suspicion of CAP.

The Severity of Acute Pancreatitis According to Modified Balthazar Classification in Patients With Pancreatic Cancer

OBJECTIVE

Although acute pancreatitis (AP) is a self-limited disease under supportive and medical treatment, it can have life-threatening potential in some patients. Results of studies reporting outcomes of AP-associated pancreatic malignancy are controversial. The aim of this study was to evaluate the severity and prognosis of pancreatic cancer (PC)-related AP by modified Balthazar score.

METHODS

A total of 354 patients hospitalized and followed up in our clinic between 2013 and 2019 were included in the study. Demographic data of all patients were recorded. The etiology of all cases was determined. According to the etiology, the cases were divided into 2 groups: AP related to pancreatic malignancy and AP due to nonmalignant causes. The patients underwent computed tomography of the abdomen within the first 12 hours of admission and after 3 to 7 days. Patients were evaluated and classified by modified Balthazar classification.

RESULTS

Malignancy-related AP was detected in 18 (5.1%) patients. A total of 336 cases (94.9%) were related to nonmalignant causes. There was no statistically significant difference in the severity of AP in both groups at admission and after 3 days (p > 0.05). The changes (regression, progression, or no change) in the disease severity at the first and the subsequent imaging were examined. There was no significant relationship between the 2 groups (p > 0.05).

CONCLUSION

AP may be the clinical manifestation of PC or PC may induce AP in various ways. It was shown that the underlying malignancy did not adversely affect the severity and course of AP.