The value of ultrasound in staging the severity of acute pancreatitis

The authors asses the accuracy and role of early ultrasound examination in staging the severity of acute pancreatitis. A total of 110 consecutive patients with acute pancreatitis were included into the study. The ultrasound findings were categorized into six categories and compared with a modification of multiple prognostic criteria, computerized tomography, operative findings (when available) and clinical outcome. The probability of a positive ultrasound finding in a patient with clinically severe acute pancreatitis was 89.6% (sensitivity). In comparison to computerized tomography the sensitivity of ultrasound in discovering CT diagnosed moderate and severe forms of acute pancreatitis was 86.6%. The sensitivity of ultrasound in discovering moderate and severe forms of acute pancreatitis as defined at laparotomy was 77.8%. The specificity of ultrasound was low (44.0%) in comparison with modified prognostic criteria, but high in comparison with computerized tomography (87.5%) and staging at laparotomy (85.7%). There was a good correlation between US defined moderate and severe forms of acute pancreatitis and clinical outcome (average number of hospital days and case fatality). The authors conclude that early ultrasound examination in acute pancreatitis is indicated and can help stage the severity of the disease and affect decision making.     

Evaluation of severity in acute pancreatitis

Recently we reviewed 240 patients with acute pancreatitis admitted to our service and the affiliated hospitals for five years. Clinical symptoms and laboratory data of these cases were analyzed depending on their prognosis. The grades were divided into 3 groups by the mortality rates: Grade I with the mortality rate of less than 10%, Grade II 10-20%, and Grade III with greater than 20%. Clinical symptoms in Grade III were shock and neurological or dermatological symptoms. On the other hand, laboratory findings in Grade III were as follows; blood sugar was more than 200 mg/dl, LDH greater than or equal to 600 IU%, BUN greater than or equal to 40 mg/dl, serum Ca less than or equal to 7.5mg/dl, T.Bil. greater than or equal to 5.0 mg/dl, blood pressure less than or equal to 90 mmHg, and PaO2 less than or equal to 65 mmHg (room air). The degree of severity of acute pancreatitis was divided into 3 types, as follows: Mild; all belong to Grade I, or less than 2 positives of Grade II. Moderate; 3 to 4 positives of Grade II, or one positive of Grade III. Severe; 5 positives or more of Grade II, or 2 positives or more of Grade III. Our criteria with both clinical and laboratory findings are very useful for the evaluation of the severity and choice of treatment in acute pancreatitis.     

SIRS及PMN-弹力蛋白酶在急性胰腺炎中的临床意义

为探讨全身炎症反应综合征(SIRS)与PMN—弹力蛋白酶在判断急性胰腺炎病情中的临床意义。根据分级标准，将收治的急性胰腺炎区分为轻型和重症，分析判断胰腺炎严重度与SITS、血浆PMN—弹力蛋白酶浓度之间的关系。结果显示，SIRS判断急性胰腺炎严重度的敏感性、特异性及准确率为94．1％，60％和78．1％。重症胰腺炎血浆中PMN—弹力蛋白酶浓度明显上升，其中合并脏器功能障碍者上升更为显著。提示SIRS是脏器功能障碍发生的早期预报，而PMN—弹力蛋白酶可作为一种严重SIRS的标志物。     

Significance of endothelial molecular markers in the evaluation of the severity of acute pancreatitis

Purpose  In acute pancreatitis, neutrophil elastase is secreted which damages the endothelial cells. This study was designed to demonstrate that the plasma levels of soluble E-selectin (sES) and soluble thrombomodulin (sTM) serve as endothelial molecular markers; the former is used as an endothelial activation marker, while the latter, as an endothelial injury marker. Methods  A total of 27 acute pancreatitis patients were enrolled. The plasma sES and sTM levels were assessed for 10 days after admission. Results  The plasma sES levels of all the patients in different disease stages were elevated at the time of admission day (day 1). The plasma sTM levels correlated with the severity and prognosis of acute pancreatitis. The required cutoff to predict a fatal outcome was set as 32 Teijin Units (TU)/ml (sensitivity, 80%; specificity, 91%). On day 1, the mortality rate of patients with the sTM levels of ≥32 TU/ml (67%, 4/6) was significantly higher than of those with the sTM levels of <32 TU/ml (5%, 1/21). Conclusion  These results indicated that (1) the activation of the vascular endothelial cells and the resultant increase in the plasma sES levels might be evoked in all disease stages, and (2) an elevation of the plasma sTM level, which indicates the presence of vascular endothelial injury, might therefore result in a poor prognosis. S. Ida and Y. Fujimura have contributed equally to this work.     

C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis

In a series of patients with acute pancreatitis we have studied complement factors, antiproteases (alpha 2-macroglobulin and alpha 1-antiprotease) and C-reactive protein to determine the value of their sequential measurement in the prediction of outcome relative to clinical assessment and current multiple factor scoring systems. Complement factors were unhelpful in predicting the severity of an attack. alpha 2-Macroglobulin levels were significantly lower in complicated attacks during days 3-8 and alpha 1-antiprotease levels were significantly higher during days 4-8. C-reactive protein concentrations showed the best discrimination between mild and complicated attacks, levels rising higher and persisting for longer in complicated attacks; these differences were highly significant from day 2 (the morning after admission) to day 8. The concentrations providing the best discrimination were found to be greater than or equal to 210 mg/l for the peak C-reactive protein (on the second, third or fourth day) and greater than or equal to 120 mg/l for the C-reactive protein at the end of the first week. Analysis demonstrated both the peak or seventh-day C-reactive protein concentration to be of similar accuracy to either the Ranson or Glasgow multiple factor scoring systems and slightly better for attacks associated with gallstones. The C-reactive protein assay is simple, quick to perform, provides useful clinical information and is more likely to be of value and to be adopted into routine clinical practice than multiple factor scoring systems.     

急性胰腺炎危重程度评估方法的研究

急性胰腺炎(acute pancreatitis, AP)是临床常见的急腹症之一,死亡率一直居高不下.近数十年在AP的诊治等方面虽均有进步,但仍有20%～30%的患者临床经过凶险,总体死亡率达5%～10%[1].AP分为轻症急性胰腺炎(mild acute pancreatitis, MAP)及重症急性胰腺炎(severe acute pancreatitis,SAP),MAP病情相对较轻,预后较好,而SAP常引起严重的全身或局部并发症,病死率高.     

急性胰腺炎危重程度评估方法的研究

急性胰腺炎(acute pancreatitis, AP)是临床常见的急腹症之一,死亡率一直居高不下.近数十年在AP的诊治等方面虽均有进步,但仍有20%～30%的患者临床经过凶险,总体死亡率达5%～10%[1].AP分为轻症急性胰腺炎(mild acute pancreatitis, MAP)及重症急性胰腺炎(severe acute pancreatitis,SAP),MAP病情相对较轻,预后较好,而SAP常引起严重的全身或局部并发症,病死率高.     

各评分系统对胰腺炎疾病严重程度预测价值的临床研究

目的：探讨各评分系统对急性胰腺炎（acute pancreatitis,AP）疾病严重程度预测价值的差异。方法回顾性分析156例 AP 患者的临床资料,记录患者入院时的 c-反应蛋白（CRP）等实验室检测值,结合中国胰腺炎诊治指南（2007）将患者分为轻症胰腺炎（mild acute pancreatitis, MAP）组、重症胰腺炎（severe acute pancreatitis,SAP）组。按照各评分系统的相应评分标准对患者进行急性生理学和慢性健康状况评分（APACHEⅡ）、Ranson、BISAP、CTSI 评分。按照APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 的标准分别将患者区分为 MAP 组、SAP 组,ROC 曲线比较各评分系统对 AP 疾病严重程度预测价值的差异。结果156例 AP 患者,确诊为 SAP21例,另135例诊断为 MAP。APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 预测 SAP 的 AUC 分别为0．78（95％CI：0．70～0．84）,0．69（95％CI：0．62～0．76）,0．74（95％CI：0．66～0．80）,0．69（95％ CI：0．61～0．76）,0．68（95％CI：0．57～0．78）,各评分系统间差异无统计学意义。结论各评分系统对 SAP 的预测价值差异无统计学意义,在临床工作中,SAP 的早期预测应参考多种评价体系,临床获取及应用更为简便的单一实验室指标的参考意义,值得进一步深入研究。     

Frequency and severity of acute pancreatitis in chronic dialysis patients.

BACKGROUND: The incidence and severity of acute pancreatitis in patients undergoing dialysis treatment are unknown. METHODS: A questionnaire asking for the incidence and the severity of a first attack of acute pancreatitis in chronic dialysis patients in the year 2002 was sent to the members of QuaSi-Niere gGmbH, an organization representing almost all dialysis centres in Germany. A second questionnaire was sent to those who reported such patients. RESULTS: Response rates for the first and second questionnaire were 72% (832 out of 1150 centres) and 100% (72 out of 72 centres), respectively. After the exclusion of patients with invalid data, 55 patients with acute pancreatitis remained: 46 patients out of 68 715 haemodialysis (HD) patients (incidence rate 67/100 000/year; 95% confidence interval, 49 to 89/100 000/year) and 9 out of 3386 peritoneal dialysis (PD) patients (incidence rate 266/100 000/year; 95% confidence interval, 122 to 504/100 000/year; Fisher's exact test: P = 0.002). Twenty-eight patients (51%) had a known risk factor for acute pancreatitis. When these were excluded, the incidence of pancreatitis of unknown aetiology was 32/100 000/year (20-48) for HD patients (n, 22) and 148/100 000/year (48-345) for PD patients (n, 3; Fisher's exact test: P = 0.016). PD patients required hospital admission more frequently than HD patients (100% versus 76%) and suffered more frequently from necrotizing pancreatitis (50% versus 19%). CONCLUSIONS: Dialysis-especially PD-is another risk factor that increases the susceptibility of the pancreas to acute pancreatitis. Acute pancreatitis in patients undergoing PD is more frequent and seems to be more severe than in those receiving HD treatment.     

The value of immunoreactive lipase in acute pancreatitis.

We have evaluated a new agglutination test for serum immunoreactive lipase in 24 patients with abdominal pain and hyperamylasaemia. On admission all 20 patients with acute pancreatitis had a positive lipase test, 3 of the 4 patients who did not have pancreatitis had a negative lipase test. The sensitivity of the lipase test on day 1 is 100%, the specificity 96% and predictive value of a positive test is 95.2% compared to 83% for amylase. A negative test excludes pancreatitis. In addition, the test stays positive longer than hyperamylasaemia.     

Hs-CRP在妊娠合并急性胰腺炎严重性的预测价值及其机制

目的探讨高敏C-反应蛋白在妊娠合并急性胰腺炎严重性的预测价值及其机制。方法收集65例妊娠合并急性胰腺炎患者,依据Ranson评分标准,将患者分为轻型胰腺炎（30例）和重型胰腺炎（35例）,分别于入院时,第3天及第7天检测两组患者外周血白细胞总数、血浆谷丙转氨酶、尿素氮及高敏C-反应蛋白水平。结果重型胰腺炎患者血淀粉酶及脂肪酶均明显高于轻型患者（P〈0.05）;入院时、第3天及第7天,轻型胰腺炎患者外周血白细胞总数、血浆谷丙转氨酶、尿素氮及高敏C-反应蛋白水平均明显低于重型胰腺炎患者（P〈0.05）;血浆高敏C-反应蛋白水平与谷丙转氨酶和尿素氮水平呈正相关,相关系数分别为r=0.927,P〈0.05和r=0.934,P〈0.05。两组患者甘油三酯及总胆固醇水平无明显差别。结论血浆高敏C-反应蛋白水平可以在一定程度上预测妊娠合并急性胰腺炎患者严重程度,其机制可能与血浆Hs-CRP水平能够反应患者肝功能及肾功能损害有关。     

急性胰腺炎严重程度评分系统的临床研究进展

急性胰腺炎（acute pancreatitis,AP）是临床最常见的急腹症之一,近年来经过国内外学者共同努力,急性胰腺炎病死率和并发症发生率明显下降,但重症急性胰腺炎（severe acute pancreatitis,SAP）的病死率仍居高不下,临床早期识别SAP对改善患者预后至关重要。自提出AP严重程度评分后,临床判断病情严重程度便有了依据。随着疾病研究的进展,对临床初步判断AP病情严重程度的评分系统日益繁多,本文对目前临床使用较广泛的几种AP严重程度经典评估系统及近年来的研究进展做简单综述。     

Effects of octreotide on acute pancreatitis of varying severity in rats.

OBJECTIVE: To find out the effects of the octreotide on the course of acute pancreatitis in rats. DESIGN: Prospective laboratory study. SETTING: Medical school, Turkey ANIMALS: 184 Sprague-Dawley rats, 120 of which were randomly allocated into 8 groups of 15 each for the survival study, and the remainder of which were randomly allocated into 8 groups of 8 rats each for assessment of biochemical variables and histological score. INTERVENTIONS: The same 8 groups were used for the two parts of the study: saline alone (control), octreotide alone (control), oedematous pancreatitis induced by cerulein with and without octreotide, moderate pancreatitis induced by low-dose glycodeoxycholic acid and cerulein with and without octreotide, and severe pancreatitis induced by high-dose glycodeoxycholic acid and cerulein with and without octreotide. MAIN OUTCOME MEASURES: Mortality, results of biochemical tests, and histological score. RESULTS: No rats in the control groups died. Of those with oedematous pancreatitis 1 died that had not been given octreotide (7%) and 2 that had (13%). In the moderate pancreatitis groups 4 that had not been given octreotide died (27%) compared with one that had (7%). In the severe pancreatitis group 7 that had not had octreotide died (46%) compared with 6 that had (40%). Octreotide caused a reduction in serum amylase and lactate dehydrogenase activity in all groups, but reduced aspartate aminotransferase only in those rats with moderate pancreatitis. It prevented hypocalcaemia in rats with severe pancreatitis, but had no effect on serum electrolyte concentrations, alkaline phosphatase activity, or blood gas analyses. Rats with moderate pancreatitis that had been given octreotide had less tissue oedema, acinar necrosis, and inflammatory cell infiltration. In those with severe pancreatitis there was less tissue oedema but more acinar necrosis. CONCLUSION: If octreotide is given early in the course of the disease it may result in improved outcome, but it seems to be ineffective in severe pancreatitis in which acinar necrosis is already established.     

Clinical value of lipopolysaccharide-binding protein (LBP) determinations in acute pancreatitis

Background Lipopolysaccharide-binding protein (LBP) is a class 1 acute-phase protein that binds and transfers bacterial lipopolysaccharide (LPS). This study investigated the clinical value of measuring LBP for stratifying biochemical severity in acute pancreatitis by using a recently developed fully automated assay technique.Patients and methods We studied 71 patients with acute pancreatitis of whom 41 presented with a necrotizing course. Necrotizing pancreatitis was associated with pancreatic infections in 21 patients and with multiorgan dysfunction syndrome (MODS) in 18 patients. Serum LBP was measured for 14 days by a fully automated immunoassay and CRP was assessed on a daily routine basis.Results The relative quantitative systemic release of LBP was lower than that observed for CRP; however, the two parameters revealed similar dynamics, with a maximum increase in acute pancreatitis around the fourth day after onset of symptoms. As observed for CRP, LBP was significantly higher in patients who developed complications such as necrosis, pancreatic infections, single or combined MODS than in those who did not. Multiple regression analysis revealed that pulmonary failure and MODS were independent variables associated with enhanced LBP release, while the development of necrosis, pancreatic infections and MODS were the corresponding variables for increased CRP levels.Conclusions Systemic LBP concentrations are significantly elevated in acute pancreatitis and closely correlate with overall disease severity. However, compared with CRP, LBP does not contribute to an improved severity stratification in acute pancreatitis.     

JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis

This article addresses the criteria for severity assessment and the severity scoring system of the Ministry of Health and Welfare of Japan; now the Japanese Ministry of Health, Labour, and Welfare (the JPN score). It also presents data comparing the JPN score with the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson score, which are the major measuring scales used in the United States and Europe. The goal of investigating these scoring systems is the achievement of earlier diagnosis and more appropriate and successful treatment of severe or moderate acute pancreatitis, which has a high mortality rate. This article makes the following recommendations in terms of assessing the severity of acute pancreatitis: (1) Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis (Recommendation A). (2) Assessment by a severity scoring system (JPN score, APACHE II score) is important for determining treatment policy and identifying the need for transfer to a specialist unit (Recommendation A). (3) C-reactive protein (CRP) is a useful indicator for assessing severity (Recommendation A). (4) Contrast-enhanced computed tomography (CT) scanning and contrast-enhanced magnetic resonance imaging (MRI) play an important role in severity assessment (Recommendation A). (5) A JPN score of 2 or more (severe acute pancreatitis) has been established as the criterion for hospital transfer (Recommendation A). (6) It is preferable to transfer patients with severe acute pancreatitis to a specialist medical institution where they can receive continuous monitoring and systemic management.     

Prognostication of severity of the course in acute pancreatitis

The authors picked out 200 case records of the patients with acute pancreatitis using a method of random sample. By means of the method of step-by-step discriminant analysis, the severity of the course of the disease was prognosticated. The age of a patient, duration of the disease, body temperature, leukocytic count and glucose level in the blood, amylase activity in the urine, presence of another pathology were analysed. The solving rule permitting to prognosticate an outcome of the disease with a high degree of probability was obtained. A variable directly dependent on the severity of a course of the disease--"degree of the severity of acute pancreatitis" was established.     

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急性胰腺炎的严重程度分级对临床实践和研究具有重要的意义。国际胰腺病协会通过广泛的专家讨论,把对急性胰腺炎病情变化有决定性影响的因素分成局部和全身因素。局部影响因素指胰腺或胰腺周围组织的坏死,统称为围胰腺坏死;全身影响因素系指由急性胰腺炎引起的远处器官功能异常,即器官功能衰竭。通过将不同严重程度的局部和全身因素的组合,将急性胰腺炎分成轻度、中度、重度、危重四级。该分级系统的特点是依据临床现实的危险因素确定急性胰腺炎的严重程度,而不是一些生化和生理指标。本分级系统的基础是大量的回顾性分析,尚需前瞻性研究验证。     

Predictors of severity of attacks of acute pancreatitis

In an attempt to reduce the current morbidity and mortality from acute pancreatitis, a prospective randomized multicentre trial was begun in August 1982. Part of this study involved an attempt to develop a set of prognostic indices which would identify patients with severe pancreatitis on the day of admission to hospital. An analysis of a predetermined set of 10 indices (age, blood pressure, white cell count, blood urea, serum calcium, aspartate aminotransferase, lactate dehydrogenase, blood glucose, arterial blood pH and PO2) on admission to hospital, in 100 patients, is presented. The positive predictive value of these indices (excluding age) is 90%. These indices are readily available in most hospitals, and allow the early identification of the high risk patient with an accuracy equal to or better than that previously reported.