Hemoconcentration is a poor predictor of severity in acute pancreatitis

Predicting in-hospital mortality in patients with acute pancreatitis in the ED: a direct, retrospective comparison of four clinical and radiological prognostic scores

BACKGROUND

Acute pancreatitis can be a severe disease that significantly impacts patients' quality of life and outcome. The clinical course is variable and predictive scoring systems have a debated role in early prognosis. This study aims to compare the prognostic accuracy of Balthazar, BISAP, HAPS and SOFA scores in the prediction of in-hospital mortality in patients with acute pancreatitis.

METHODS

This is a retrospective, single-center cohort study conducted in the Emergency Department of a third-level university hospital. Patients aged >18 years admitted from 1st January 2018 to 31st December 2021 for the first episode of acute pancreatitis were included.

RESULTS

A total of 385 patients (mean age of 65.4 years and 1.8% in-hospital mortality) were studied. Balthazar, BISAP and SOFA scores were significantly higher in patients with in-hospital mortality and AUROCs were equal to 0.95 (95% CI 0.91-0.99, P<0.001), 0.96 (95% CI 0.89-1, P=0.001), 0.91 (95% CI 0.81-1, P=0.001) with no differences among them and absence of in-hospital mortality in patients with HAPS=0.

CONCLUSIONS

Our data support the concept that clinical prediction scores can be useful for risk stratification in the Emergency Department. However, no single score has shown superiority in predicting acute pancreatitis-related in-hospital mortality among tested tools.

Predicting the severity of acute pancreatitis: Current approaches and future directions

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.

Comparison of clinical characteristics and outcomes between alcohol-induced and gallstone-induced acute pancreatitis: An Australian retrospective observational study

OBJECTIVES

To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis.

METHODS

Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition.

RESULTS

A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p < 0.0001). On multivariable regression analysis, Bedside Index of Severity in Acute Pancreatitis score (estimate: 0.393; standard error: 0.058; p < 0.0001) and admission haematocrit (estimate: 0.025; standard error: 0.008; p = 0.002) were found to be independently associated with prolonged hospital length of stay.

CONCLUSION

Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.

Effectiveness and safety of proton pump inhibitors for treating acute pancreatitis: A protocol for systematic review and meta analysis

BACKGROUND

Previous studies have showed that anti-acid therapy with proton pump inhibitors (PPIs) can inhibit pancreatic secretion and it may be used in treating acute pancreatitis (AP). But at present, there is no systematic reviews for the evidence and the therapeutic effectiveness and safety of anti-acid therapy with PPIs in AP were not unclear. Therefore, we will undertake a systematic review of the literature to summarize previous evidence regarding this topic, in order to clarify the effectiveness and safety of anti-acid therapy with PPIs in AP.

METHODS

We will search the EMBASE, WANFANG DATA, Web of Knowledge, China National Knowledge Infrastructure, PubMed, ClinicalTrials.gov and Cochrane Library from inception to June 30,2021 to retrieve relevant studies using the search strategy: ("Proton pump inhibitors" OR "PPI" OR "PPIs" OR "Omeprazole" OR "Tenatoprazole" OR "Pantoprazole" OR "acid suppression therapy" OR "acid suppression drugs") AND ("pancreatitis" OR "pancreatitides"). Two authors independently judged study eligibility and extracted data. Heterogeneity will be examined by computing the Q statistic and I2 statistic.

RESULTS

This study assessed the efficiency and safety of proton pump inhibitors for treating acute pancreatitis.

CONCLUSIONS

This study will provide reliable evidence-based evidence for the clinical application of PPIs for treating AP.

ETHICS AND DISSEMINATION

Ethical approval is unnecessary as this protocol is only for systematic review and does not involve privacy data. The findings of this study will be disseminated electronically through a peer-review publication or presented at a relevant conference.

Effectiveness and safety of Liuhedan for treating acute pancreatitis: A protocol for systematic review and meta analysis

BACKGROUND

Liuhedan is a famous traditional Chinese medicine (TCM) formula used to treat acute pancreatitis (AP) in China. However, there is no systematic reviews for the evidence and the therapeutic effectiveness and safety of Liuhedan for treating AP. The aim of this study is to summarize previous evidence, assessing the efficacy and safety of Liuhedan in the treatment of AP.

METHODS

We will search the EMBASE, WANFANG DATA, Web of Knowledge, CNKI, PubMed, ClinicalTrials.gov and Cochrane Library from inception to June 30, 2021 to retrieve relevant studies using the search strategy: ("Liuhedan" OR "Liuhe Pill" OR "Liu-He-Dan") AND ("pancreatitis" OR "pancreatitides"). Two authors independently judged study eligibility and extracted data. Heterogeneity will be examined by computing the Q statistic and I2 statistic.

RESULTS

This study assessed the efficiency and safety of Liuhedan for treating acute pancreatitis.

CONCLUSIONS

This study will provide reliable evidence-based evidence for the clinical application of Liuhedan for treating AP.

ETHICS AND DISSEMINATION

Ethical approval is unnecessary as this protocol is only for systematic review and does not involve privacy data. The findings of this study will be disseminated electronically through a peer-review publication or presented at a relevant conference.

Efficiency of red cell distribution width in predicting severity and mortality of patients with acute pancreatitis: A protocol for systematic review and meta-analysis

BACKGROUND

Previous studies have showed that red cell distribution width (RDW) may be an inflammatory status, and it may be used to predict prognosis of acute pancreatitis (AP). However, there are no systematic reviews for the evidence, and the association between RDW and AP is still not completely understood. Therefore, we will undertake a systematic review of the literature to summarize previous evidence regarding this topic, in order to clarify the value of RDW predicting prognosis of patients with AP.

METHODS

We will search EMBASE, Web of Knowledge, PubMed, ClinicalTrials.gov and Cochrane Library from their inception to Mar 2021 to retrieve relevant studies. Two authors independently judged study eligibility and extracted data. Heterogeneity will be examined by computing the Q statistic and I2 statistic.

RESULTS

This study proved the Efficiency of RDW in predicting mortality and severity of patients with AP. And provided easy method for clinical evaluation for AP patients.

CONCLUSIONS

The findings of this systematic review will show the value of RDW predicting prognosis of patients with AP.

ETHICS AND DISSEMINATION

Ethical approval is unnecessary as this protocol is only for systematic review and does not involve privacy data. The findings of this study will be disseminated electronically through a peer-review publication or presented at a relevant conference.

The Relationship Between Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios With Hospital Stays and Mortality in the Emergency Department

Background Most acute pancreatitis scoring is made in the first 48-72 hours or later. Like many inflammatory processes, Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) can be useful in showing the severity and extent of inflammation in acute pancreatitis. Our study aimed to evaluate whether these rates affect mortality according to the NLR and PLR values ​​of patients diagnosed with acute pancreatitis by examining the blood samples taken within the first hour after admission to the emergency department rates are useful in predicting the length of stay. Methods In our retrospective study, 557 patients applied to our clinic for 4.5 years, whose amylase and lipase values ​​were higher than two times the cut-off value in blood tests and whose CT imaging was compatible with acute pancreatitis were included in the study. Results The median length of hospitalization of the patients was 4.0 (3.0-6.0) days. Gallstones were detected in 320 (57.5%) patients. Mortality of less than a year was observed in 45 (8.1%) of the study population. Eighteen of the patients (3.2%) showed the need for follow-up in the intensive care unit. A statistically significant relationship was found between mortality and variables hematocrit (HCT), red cell distribution width (RDW),c-reactive protein CRP), glucose, urea, potassium, albumin, PLR, and NLR (p <0.05). A statistically significant correlation was observed between RDW, NLR, glucose, and CRP levels in the two groups divided according to the median value of 4 days we found on hospitalization (p <0.05). According to the graphics and test results obtained by ROC analysis, the mortality status can be predicted at a statistically significant level with PLR and NLR diagnostic tests (p <0.05). Conclusion High levels of NLR, PLR, RDW, glucose, CRP, urea, potassium, low albumin and hematocrit values ​​at the first admission in the Emergency Service seem to be associated with increased 1-year mortality in acute pancreatitis.

Evaluation of the BISAP scoring system in prognostication of acute pancreatitis - A prospective observational study

INTRODUCTION

Severe acute pancreatitis has a high mortality and its early identification is important for management and risk stratification. The bedside index for severity in acute pancreatitis (BISAP) is a simple scoring system done at admission which predicts the severity of pancreatitis. Procalcitonin is an inflammatory marker which is raised very early and helps in early prediction of the severity of disease. This study aims to evaluate the BISAP score and Procalcitonin in prognostication of acute pancreatitis.

METHODS

A prospective observational study of 60 patients presenting with acute pancreatitis was done at XXX Medical College and Hospital from July 2015 to June 2016. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. Procalcitonin card test was done for all patients. The patients were stratified according by BISAP score and procalcitonin positivity into categories of severe pancreatitis, organ failure and pancreatic necrosis, as well as the number of deaths. The comparison of BISAP with other scoring systems, Procalcitonin (PCT), C-reactive protein (CRP), hematocrit, and body mass index (BMI) was done by the area under the receiver-operating curve (AUC) to prediction of severe acute pancreatitis, organ failure, necrosis, and death.

RESULTS

Of the 60 patients, 14 (23.3%) developed severe acute pancreatitis, 11 (18.3%) Organ failure, 21 (35%) pancreatic necrosis and 7 (11.6%) died. A BISAP score of ≥3 was a statistically significant cutoff value. AUCs for predicting severe pancreatitis and death of BISAP were 0.875 and 0.740respectively, similar to those for Ranson criteria (0.802, 0.763) and APACHE-II (0.891, 0.769) and greater than AUCs for CTSI (0.641, 0.554). The AUC for prediction of organ failure were 0.906, 0.833, 0.874 and 0.623 for BISAP, Ranson criteria, APACHE-II, and CTSI respectively. AUCs for PCT predicting severity, organ failure, and death were 0.940, 0.923 and 0.769 respectively were similar to BISAP but greater than those for CRP (0.755, 0.719, 0.693), hematocrit (0.540, 0.570, 0.550), and BMI (0.493, 0.523, 0.497).

CONCLUSION

The BISAP predicts severity, organ failure and death, in acute pancreatitis very well.It is as good as APACHE-II but better than Ranson criteria, CTSI, CRP, hematocrit, and BMI. PCT is a promising inflammatory marker with prediction rates similar to BISAP.

BISAP, RANSON, lactate and others biomarkers in prediction of severe acute pancreatitis in a European cohort

BACKGROUND AND AIM

The study aims to assess and compare the predicting ability of some scores and biomarkers in acute pancreatitis.

METHODS

We prospectively collected data from 269 patients diagnosed of acute pancreatitis, admitted to Virgen de las Nieves University Hospital between June 2010 and June 2012. Blood urea nitrogen (BUN), C-reactive protein, and creatinine were measured on admission and after 48 h, lactate and bedside index for severity acute pancreatitis (BISAP) only on admission and RANSON within the first 48 h. Definitions from 2012 Atlanta Classification were used. Area under the curve (AUC) was calculated for each scoring system for predicting severe acute pancreatitis (SAP), mortality, and intensive care unit (ICU) admission, obtaining optimal cut-off values from the receiver operating characteristic curves.

RESULTS

Eight (3%) patients died, 17 (6.3%) were classified as SAP, and 10 (3.7%) were admitted in ICU. BISAP was the best predictor on admission for SAP, mortality, and ICU admission with an AUC of 0.9 (95% CI 0.83-0.97); 0.97 (95% CI 0.95-0.99); and 0.89 (95% CI 0.79-0.99), respectively. After 48 h, BUN 48 h was the best predictor of SAP (AUC = 0.96 CI: 0.92-0.99); BUN 48 h and BISAP were the best predictors for mortality (AUC = 0.97 CI: 0.95-0.99) and creatinine 48 h for ICU admission (AUC = 0.96 CI: 0.92-0.99). Lactate showed an AUC of 0.79 (CI: 0.71-0.88), 0.87 (CI: 0.78-0.96), and 0.77 (CI: 0.67-0.87) for SAP, mortality, and ICU admission, respectively. All parameters were predictors for SAP, mortality, and ICU admission, but C-reactive protein on admission was only a significant predictor of SAP.

CONCLUSION

Bedside index for severity acute pancreatitis is a good predictive system for SAP, mortality, and ICU admission, being useful for triaging patients for ICU management. Lactate could be useful for developing new scores.

Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis

OBJECTIVES

Systemic levels of soluble urokinase-type plasminogen activator receptor (suPAR) are increased in various inflammatory and infectious diseases. We investigated the activation and prognostic value of plasma suPAR (P-suPAR) in patients experiencing their first acute alcohol pancreatitis (AAP).

METHODS

From prospectively collected data, we measured P-suPAR concentrations in 104 patients with AAP during hospitalization and again after discharge.

RESULTS

According to the revised Atlanta classification, pancreatitis was moderately severe in 29 (28%) and severe in 6 (6%) patients and these severities were combined for further analysis (non-mild AAP, n = 35; 34%). Median P-suPAR levels were significantly higher in patients with AAP during hospitalization than after discharge (4.8 vs 3.1 ng/mL; P < 0.001) and in non-mild compared to mild AAP (6.2 vs 4.2 ng/mL; P < 0.001). When the analysis was made 1 to 4 days after admission (n = 68), the area under the curve was 0.81 (95% confidence interval, 0.70-0.92). P-suPAR was found to be a better prognostic marker in AAP than C-reactive protein, hematocrit, or creatinine.

CONCLUSIONS

P-suPAR concentrations are elevated in AAP and correlate with the severity of the disease. These results suggest that P-suPAR may have potential to serve as a novel prognostic marker for AAP severity on admission.

Detrimental effect of high volume fluid administration in acute pancreatitis - a retrospective analysis of 391 patients

BACKGROUND

Early fluid resuscitation is recommended for the therapy of acute pancreatitis in order to prevent complications. There are, however, no convincing data supporting this approach.

METHODS

We reviewed 391 consecutive cases of confirmed acute pancreatitis. Admitting physicians had been advised to administer an aggressive fluid resuscitation in the early phase of disease, if possible. We tested whether disease severity according to the revised Atlanta Classification, local complications, and maximum C-reactive protein levels were predictable by the initial volume therapy in logistic and linear regression models, respectively. We also determined which parameters on admission encouraged a more aggressive fluid resuscitation.

RESULTS

The recorded fluid administered within the first 24 h was 5300 [3760; 7100] ml (median [1st; 3rd quartile]). More aggressive volume therapy was associated with disease severity and a higher rate of local complications. There was a linear relationship between administered volume and the maximum C-reactive protein. The amount of administered fluid was significantly attributed to age, hematocrit, and white blood cell count on admission. When adjusted for these parameters the impact of administered volume on outcome was still present but attenuated.

CONCLUSIONS

We found detrimental effects of fluid therapy on major outcome parameters throughout the whole range of administered volume. More volume was administered in younger patients and in patients with evidence of hemoconcentration and inflammation. The adverse effects of volume therapy persisted after elimination of these parameters. Caution should therefore be advised with regards to volume therapy in patients with acute pancreatitis.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure

BACKGROUND

The early identification of severe acute pancreatitis is important for the management and for improving outcomes. The bedside index for severity in acute pancreatitis (BISAP) has been considered as an accurate method for risk stratification in patients with acute pancreatitis. This study aimed to evaluate the comparative usefulness of the BISAP.

METHODS

We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007 to December 2010. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. We stratified the number of patiants with severe pancreatitis, pancreatic necrosis, and organ failure as well as the number of deaths by BISAP score. We used the area under the receiver-operating curve (AUC) to compare BISAP with other scoring systems, C-reactive protein (CRP), hematocrit, and body mass index (BMI) with regard to prediction of severe acute pancreatitis, necrosis, organ failure, and death.

RESULTS

Of the 303 patiants, 31 (10.2%) were classified as having severe acute pancreatitis. Organ failure occurred in 23 (7.6%) patients, pancreatic necrosis in 40 (13.2%), and death in 6 (2.0%). A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis, organ failure, and mortality. AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86, respectively, which were similar to those for APACHE-II (0.80, 0.87) and Ranson criteria (0.74, 0.74) and greater than AUCs for CTSI (0.67, 0.42). The AUC for organ failure predicted by BISAP, APACHE-II, Ranson criteria, and CTSI was 0.93, 0.95, 0.84 and 0.57, respectively. AUCs for BISAP predicting severity, organ failure, and death were greater than those for CRP (0.69, 0.80, 0.72), hematocrit (0.45, 0.35, 0.14), and BMI (0.41, 0.47, 0.17).

CONCLUSION

The BISAP predicts severity, death, and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria, CTSI, CRP, hematocrit, and BMI.

[Fluid therapy in acute pancreatitis]

Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.

Early measures of hemoconcentration and inflammation are predictive of prolonged hospitalization from post- endoscopic retrograde cholangiopancreatography pancreatitis

OBJECTIVES

Hemoconcentration markers are predictors of severe acute pancreatitis but have not been specifically evaluated in post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP).

METHODS

Case-control study of patients undergoing ERCP for suspected sphincter of Oddi dysfunction. We identified patients with PEP (PEP positive) and controls (PEP negative) in a 1:2 ratio. blood urea nitrogen (BUN) and hematocrit (Hct) were measured before procedure, upon admission, and 24 hours later. Preprocedure levels of BUN and Hct were analyzed to control for confounders. Among the PEP-positive patients, BUN level, Hct level, and systemic inflammatory response syndrome are compared between severe and mild/moderate cases.

RESULTS

There were 149 PEP-positive patients, including 18 patients (12.1%) with severe PEP and 301 PEP-negative controls. After adjusting, higher preprocedure BUN level (odds ratio [OR], 1.05 [1.01, 1.10]; P < 0.02) and pancreatic sphincterotomy (OR, 1.60 [1.01, 2.55]; P < 0.05) were associated with PEP, whereas older age (OR, 0.98 [0.96, 0.99]; P < 0.02) and a greater body mass index (OR, 0.97 [0.94, 0.99]; P < 0.03) with a lower rate.Difference in BUN level of 0.0 or greater (failure to decline) had a sensitivity of 71% and a specificity of 79% for differentiating severe from mild/moderate PEP. Patients with severe PEP were more likely to have systemic inflammatory response syndrome upon admission (44.4% [21.5, 67.4]) and after 24 hours (61.1% [38.6, 83.6] versus mild/moderate (9.2% [4.2, 14.1], 10.6% [5.4,16.0]; P < 0.0001 for each).

CONCLUSIONS

Preprocedure BUN level is associated with the development of PEP. The preprocedure BUN level and failure of the BUN level to decline during the first 24 hours are associated with prolonged hospitalization.

Predictors of adverse outcomes in acute pancreatitis: new horizons

Acute pancreatitis (AP) continues to be a clinical challenge. The mortality of patients with AP with adverse outcomes like organ failure and infected necrosis can be as high as 43 %. Highly accurate predictors of adverse outcomes are necessary to identify the high-risk patients so that they can be meticulously monitored and managed. However, there are no ideal predictors till date. Over the past several years, a number of single- and multi-parameter predictors have been identified and tested for prediction of adverse outcomes in AP. Out of the different tools tested, blood urea nitrogen and the harmless acute pancreatitis score appears to be useful and feasible in the management of AP under Indian conditions. Other single-parameter predictors like serum creatinine, hematocrit, erythrocyte sedimentation rate, C-reactive protein, and D-dimer need to be put to further tests in high-quality prospective studies with large sample size at the community level. Multi-parameter prediction tools like the bedside index of severity of acute pancreatitis may not be appealing in day-to-day clinical practice.

The effect of gastrointestinal bleeding on outcomes of patients with acute pancreatitis: a national population-based study

OBJECTIVES

To investigate the adverse effect of gastrointestinal bleeding (GIB) in patients with acute pancreatitis (AP), accounting for the status of organ failure (OF).

METHODS

We analyzed 107,349 patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 and 2009. Patients were categorized into four groups according to the status of GIB and OF, the effect of which was assessed using multivariable analyses with generalized estimating equations models. Primary outcomes were 14-day and hospital mortality. Secondary outcomes were septic complication and prolonged hospital stay (>18 days).

RESULTS

The covariate-adjusted odds ratio for 14-day mortality, hospital mortality, septic complication, and prolonged stay all significantly increased at 4.63 (95% confidence interval [CI] 3.80-5.63), 4.22 (95% CI 3.66-4.87), 3.52 (95% CI 3.03-4.08), and 1.27 (95% CI 1.20-1.35), respectively for the patients with OF only (n = 88,561). The corresponding figures for the patients with GIB only (n = 5184) were lower but still significant at 1.44 (95% CI 1.09-1.91), 1.42 (95% CI 1.15-1.75), 1.54 (95% CI 1.19-2.00), and 1.38 (95% CI 1.28-1.48). The co-existence of GIB in patients with OF (n = 1663) showed little additional risk of all adverse outcomes. Results of sensitivity analyses (enrolling only patients with principal diagnosis of AP) showed similar findings except that septic complication was not seen for GIB only.

CONCLUSIONS

OF poses greater adverse effects than GIB on outcomes of AP patients. Nevertheless, GIB still modestly increased the risks of prolonged stay and death in AP patients without OF.

Early hemoconcentration is associated with pancreatic necrosis only among transferred patients

OBJECTIVES

Studies evaluating hemoconcentration as a marker of necrosis in acute pancreatitis have reached different conclusions. The aim of this study was to determine the impact of transfer status on the accuracy of hemoconcentration for the prediction of pancreatic necrosis.

METHODS

We prospectively enrolled 339 patients in an observational cohort study from June 2005 to December 2007. Univariate and multivariate logistic regression analyses were used to evaluate the impact of transfer status on the relationship between hemoconcentration and necrosis. Accuracy for prediction of necrosis was measured by the area under the receiver operating characteristic curve.

RESULTS

Hemoconcentration was associated with increased risk of necrosis only among transferred patients (odds ratio [95% confidence limits], 3.6 [1.2, 10.8]). The area under the receiver operating characteristic curve for admission hematocrit for prediction of necrosis was 0.78 among the transferred patients versus 0.55 among those with primary admissions (chi2, P < 0.0001). Transferred patients had greater initial severity (median bedside index of severity in acute pancreatitis, 2 vs 1; P < 0.0001), were more likely to have hemoconcentration (44% vs 18%; chi2, P < 0.0001), and experienced increased necrosis (37.5% vs 3.6%; chi2, P < 0.0001) compared with primary admissions. After adjusting for sex, disease severity, fluid resuscitation, and transfer status, hemoconcentration was not associated with necrosis (Wald chi2, P = 0.14).

CONCLUSIONS

Transfer status is a confounder in the relationship between hemoconcentration and pancreatic necrosis.

[Evaluation of severity in acute pancreatitis]

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.

Early hemoconcentration predicts increased mortality only among transferred patients with acute pancreatitis

BACKGROUND/AIMS

The prognostic utility of hemoconcentration in acute pancreatitis (AP) remains controversial.

METHODS

We examined the relationship between early hemoconcentration and in-hospital mortality in an observational cohort study. Data was collected from 177 US hospitals from January 2004 to September 2005. Early hemoconcentration was defined as hemoglobin > or =14.6 mg/dl (hematocrit approximately 44%) at any point during the first 24 h of initial hospitalization. For transferred cases, we linked clinical data from the first hospitalization to outcomes from the second hospitalization. We then examined the impact of hospital transfer status on the prognostic utility of hemoconcentration.

RESULTS

We identified 388 (2.2%) cases as interhospital transfers. Of these, we successfully linked 198 (51.0%) to their initial hospitalization. Early hemoconcentration was associated with increased mortality among transferred cases (OR 7.4, 95% CI 1.6, 35.4). However, no such relationship existed among non-transferred cases (OR 0.9, 95% CI 0.7, 1.2). Differences in outcome between transferred vs. nontransferred cases were not explained by extent of comorbid illness or initial disease severity (either APACHE II or organ failure).

CONCLUSIONS

Early hemoconcentration predicted increased risk of mortality only among transferred cases despite similar levels of initial disease severity. These findings may help explain discordant results from prior studies of hemoconcentration in AP.

Severe acute pancreatitis: Pathogenetic aspects and prognostic factors

Approximately 20% of patients with acute pancreatitis develop a severe disease associated with complications and high risk of mortality. The purpose of this study is to review pathogenesis and prognostic factors of severe acute pancreatitis (SAP). An extensive medline search was undertaken with focusing on pathogenesis, complications and prognostic evaluation of SAP. Cytokines and other inflammatory markers play a major role in the pathogenesis and course of SAP and can be used as prognostic markers in its early phase. Other markers such as simple prognostic scores have been found to be as effective as multifactorial scoring systems (MFSS) at 48 h with the advantage of simplicity, efficacy, low cost, accuracy and early prediction of SAP. Recently, several laboratory markers including hematocrit, blood urea nitrogen (BUN), creatinine, matrix metalloproteinase-9 (MMP-9) and serum amyloid A (SAA) have been used as early predictors of severity within the first 24 h. The last few years have witnessed a tremendous progress in understanding the pathogenesis and predicting the outcome of SAP. In this review we classified the prognostic markers into predictors of severity, pancreatic necrosis (PN), infected PN (IPN) and mortality.

Markers for predicting severity and progression of acute pancreatitis

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.