Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis – An international multicenter evaluation of the revised Atlanta classification

BackgroundFor consistent reporting and better comparison of data in research the revised Atlanta classification (RAC) proposes new computed tomography (CT) criteria to describe the morphology of acute pancreatitis (AP). The aim of this study was to analyse the interobserver agreement among radiologists in evaluating CT morphology by using the new RAC criteria in patients with AP.MethodsPatients with a first episode of AP who obtained a CT were identified and consecutively enrolled at six European centres backwards from January 2013 to January 2012. A local radiologist at each center and a central expert radiologist scored the CTs separately using the RAC criteria. Center dependent and independent interobserver agreement was determined using Kappa statistics.ResultsIn total, 285 patients with 388 CTs were included. For most CT criteria, interobserver agreement was moderate to substantial. In four categories, the center independent kappa values were fair: extrapancreatic necrosis (EXPN) (0.326), type of pancreatitis (0.370), characteristics of collections (0.408), and appropriate term of collections (0.356). The fair kappa values relate to discrepancies in the identification of extrapancreatic necrotic material. The local radiologists diagnosed EXPN (33% versus 59%, P < 0.0001) and non-homogeneous collections (35% versus 66%, P < 0.0001) significantly less frequent than the central expert. Cases read by the central expert showed superior correlation with clinical outcome.ConclusionDiagnosis of EXPN and recognition of non-homogeneous collections show only fair agreement potentially resulting in inconsistent reporting of morphologic findings.     

Predictors of Vascular and Gastrointestinal Complications in Severe Acute Pancreatitis

Aim: To determine prognostic factors for arterial injury and gastrointestinal perforation in patients with severe acute pancreatitis (AP). Methods: A prospective cohort study was performed in 39 patients with AP whose Ranson scores were ≥3. The following parameters were assessed: Ranson score, APACHE II score, C-reactive protein (CRP) concentration on admission and on day 7, and contrast-enhanced computed tomography (CT) scans on admission (first CT) and between days 6 and 8 (second CT). The Balthazar CT severity index was calculated. Results: Six patients developed seven vascular and/or gastrointestinal complications (duodenal perforations in 3 and arterial pseudoaneurysm in 4). CRP on day 7 and the CT severity indices at the second CT were significantly higher in the complication group than in the noncomplication group. A stepwise logistic regression analysis demonstrated that CRP ≥15 mg/dl on day 7 and CT severity index ≥7 at the second CT were independent risk factors (p = 0.02 and 0.04, respectively). The odds ratio for CRP ≥15 mg/dl was 23.0 and 15.7 for a CT severity index of ≥7. Conclusion: A persistent elevation of the CRP concentration and a high CT severity index are independent riskfactors for local complications associated with AP. Copyright © 2008 S. Karger AG, Basel and IAP     

体质指数、血糖和血清三酰甘油与急性胰腺炎病情严重程度的关系

尽早对急性胰腺炎（AP）的病情严重程度作出准确评估,有助于快速诊断重症病例．及时开始正确的治疗。近年来,临床上起病时伴有代谢综合征（MS）的AP患者日趋多见。目的：探讨体质指数（BMI）、血糖和血清三酰甘油（TG）水平这三项MS组分指标与AP病情严重程度和预后的关系。方法：回顾2007年10月～2010年10月新疆医科大学第一附属医院住院AP患者的临床资料,分析入院时BMI、血糖、血清TG水平与Ranson评分、BalthazarCT分级、CT严重度指数（CTSI）的关系。结果：共398例AP患者纳入研究,重症患者的BMI、血糖、血清TG水平显著高于轻症患者（尸〈O．05）。Ranson评分≥3、BalthazarCT分级为D／E级和CTSI≥3的AP患者,BMI、血糖、血清TG水平分别显著高于Ranson评分〈3、BalthazarCT分级为A／B／C级和CTSI〈3的AP患者（P〈0．05）。根据Pearson相关系数,BMI、血糖、血清TG水平中的任意一项与Ranson评分、BahhazarCT分级、CTSI中的任意一项均呈显著正相关（P〈0．05）。结论：人院时BMI、血糖和血清TG水平能反映AP病情严重程度．可作为AP预后评估的参考指标。     

Update of the Atlanta Classification of Severity of Acute Pancreatitis: Should a Moderate Category Be Included?

Background: Persistent and multiple organ failure (POF and MOF) are predictive of death in acute pancreatitis (AP). Local complications without organ failure are associated with morbidity but a low risk of mortality. Aim: To design a three-category classification of AP severity and to compare it with the Atlanta Classification (AC) in terms of morbidity and mortality. Method: Severe AP was defined as death, POF (148 h) or MOF. Moderate AP was defined as the presence of acute collections and/or pancreatic necrosis. Mild AP was defined by exclusion. We compared this classification with AC in 144 episodes of AP. Results: In the three-category classification, severe AP was associated with significantly more frequent intensive care unit admission, invasive treatment and mortality than moderate and mild AP (p < 0.01). Severe AP patients required longer hospital stay and more nutritional support than mild AP patients (p < 0.01). Patients with moderate AP had significantly longer hospital stay and more need for nutritional support than patients with mild AP (p < 0.01). Five patients died, all of them with MOF and/or POF. Conclusions: A three-category classification distinguishes three homogeneous groups of severity.     

Monocyte Chemoattractant Protein 1, Active Carboxypeptidase B and CAPAP at Hospital Admission Are Predictive Markers for Severe Acute Pancreatitis

Background: CAPAP, the activation peptide of procarboxypeptidase B, is a predictor of severe acute pancreatitis (AP). Active carboxypeptidase (aCAP) may be a better predictor, as its turnover is slower. Monocyte chemotactic protein-1 (MCP-1) is an early inflammatory marker and increases before complications in severe AP. We conducted a cohort study to evaluate these markers as predictors for severe AP. Method: 140 patients with AP were included, retrospectively grouped as severe or mild by the Atlanta classification. CAPAP, MCP-1 and aCAP were analyzed in admission samples. Receiver operating characteristic curves determined high vs. low levels. Results: The levels of all markers were significantly higher in patients with severe disease. High levels of serum MCP-1 was associated with a high risk of developing severe AP (OR 40.8; 95% CI 8.5–195). High ORs were also seen for urine MCP-1 (OR 7.3; 95% CI 2.2-24.3), serum CAPAP (OR 5.4; 95% CI 1.6–17.7), urine CAPAP (OR 4.8; 95% CI 1.6–14.2), and serum aCAP (OR 3.7; 95% CI 1.2–11.3). Conclusion: Serum MCP-1 at admission was strongly associated with development of severe AP. MCP-1 in urine, CAPAP in serum and urine and aCAP may also be useful for predicting Severe AP.     

Acute pancreatitis possible initial triggering mechanism and prophylaxis

Background and Aims: Biliary acute pancreatitis or postendoscopic iatrogenia acute pancreatitis (AP) are likely triggered by autonomous arc reflexes (AAR) initiated in the peri-Vaterian duodenum (PV-D). The bilio-pancreatic duct outlet exclusion closed duodenal loops (BPDOE-CDL) model mimics these circumstances. Our aim was to validate this model and evaluate the role of AAR via their interruption with local anesthetics. Methods: Severe AP was induced in Wistar rats with the BPDOE-CDL model: extra-pancreatic insult was provoked in the PV-D by distension with 8% sodium taurocholate and methylene blue for 45 min to show the absence of duodenum pancreatic reflux. Treated experimental groups received a 2% lidocaine chlorhydrate gel instilled into the PV-D prior to triggering the AP, or before and after at the celiac-ganglia complex, or at both sites. The degree of severity was evaluated using biochemical and histopath-ological analysis. Results: Induction of AP by BPDOE-CDL was severe, with acinar and fat necrosis and hemorrhage with a greater foci number in the cephalic segment. Groups pretreated with local anesthetic developed mild or moderate AP characterized by edema and leukocyte infiltrate. Serum amylase, lipase and CRP were significantly reduced in all treated groups. Other blood metabolites and pancreatic myeloperoxidase, amylase and lipase, were significantly decreased. Conclusion: The BPDOE-CDL model was validated, emphasizing the importance of AAR as extrapancreatic initiators of AP. The interruption of AAR by lidocaine chlorhydrate prevented excessive pancreatic inflammation and diminished hemorrhage and necrosis and may prove a useful prophylactic procedure to prevent postendoscopic severe AP.     

Obesity and Fat Distribution Imply a Greater Systemic Inflammatory Response and a Worse Prognosis in Acute Pancreatitis

Background and Aims: Acute pancreatitis (AP) is a systemic inflammatory disease. It is already known that obesity and central fat distribution are related to the severity of AP, but the intimate mechanism of this relationship remains unknown. Obesity and central fat distribution are associated with an inflammatory state that could amplify the systemic inflammatory response (SIR) in AP. The aim of this study was to investigate how obesity and body fat distribution correlate with the SIR and severity of AP. Methods: 85 consecutive patients with AP were studied. Body mass index, body fat distribution and previous comorbidity were obtained at admission. The SIR was assessed by the serum levels of interleukin (IL)-Iβ, IL-1ra, IL-6, IL-8, IL-10, IL-12p70, tumor necrosis factor-α (TNF-α) and C-reactive protein. Serum concentrations of the previously mentioned cytokines were also determined in a control group of 40 healthy volunteers. Results: 63 patients (74%) had mild AP and 22 patients (26%) had severe AP. All the cytokines except IL-12p70 and TNF-α were increased in the AP group in comparison with the control group. The SIR was significantly increased in patients with severe AP. Obese patients and patients with central fat distribution had significantly more comorbidity, a higher proportion of severe AP and more intense SIR. Patients with comorbidity had a significantly higher proportion of severe AP and more SIR. Conclusion: The severity of AP in obese patients and in patients with central fat distribution seems to be related to the comorbidity and the amplification of SIR.     

A prospective evaluation of pancreatic exocrine function in patients with acute pancreatitis: Correlation with extent of necrosis and pancreatic endocrine insufficiency

Aims: The aim of this prospective study was to assess pancreatic exocrine function in patients recovering from a first attack of acute pancreatitis, and to evaluate its relationship to severity of attack, extent of pancreatic necrosis and severity of pancreatic endocrine insufficiency. Methods: Between December 2000 and November 2001, 23 patients were prospectively evaluated. Pancreatic exocrine function was measured by the faecal elastase-1 test and insufficiency was classified as moderately impaired or severely impaired. Pancreatic necrosis was determined by contrast-enhanced CT scan, and its extent was categorised according to Balthazar's classification. The severity of pancreatic endocrine insufficiency was categorised according to insulin dependence. Attacks were classified as mild (n = 16) or severe (n = 7) according to the Atlanta criteria. Results: Pancreatic exocrine insufficiency was significantly more frequent in patients recovering from severe attacks than mild (n = 6, 86% vs. n = 2, 13%; p = 0.002), and in those who developed pancreatic necrosis or pseudocyst than those who did not (6 of 7 patients vs. 2 of 16 patients, and 5 of 5 patients vs. 3 of 18 patients respectively; p = 0.002). The development of exocrine insufficiency correlated strongly with the extent of pancreatic necrosis (r = −0.754, p < 0.001), and the severity of pancreatic endocrine insufficiency (n = 4, r = −0.453, p = 0.03). Conclusion: Pancreatic exocrine insufficiency is a common occurrence in patients recovering from severe acute pancreatitis, and its severity correlates with the extent of pancreatic necrosis and the severity of concomitant pancreatic endocrine insufficiency.     

Utility of Repeated Abdominal CT Scans After Prior Negative CT Scans in Patients Presenting to ER with Nontraumatic Abdominal Pain

Purpose

The purpose of this study was to analyze diagnostic yield of repeat computed tomography (CT) after negative initial CT versus yield of initial CT in patients presenting repeatedly to emergency room (ER) for nontraumatic abdominal pain. Medical costs and radiation exposure from repeat CT could be reduced if repeat CT after negative initial CT has a low diagnostic yield.

Methods

Patients included consecutive adults presenting to William Beaumont Hospital, from 2007 to 2010, undergoing abdominal CT for nontraumatic abdominal pain retrospectively identified by medical diagnostic and CT procedural codes. Exclusion criteria were prior abdominal trauma, recent abdominal surgery, and known chronic gastrointestinal disease. The CT was labeled “positive” if findings explained patient’s abdominal pain or was clinically significant. Positivity rate was compared for repeat versus initial CT.

Results

Among 200 consecutive patients undergoing (659) multiple CTs (mean age = 45.7 years, 74 % female), positivity rate for initial CT (22.5 %) was significantly higher than positivity rates for CT#2 (8.4 %, p = 0.002), for CT#3 (4.9 %, p = 0.005), and for CT ≥ #4 (5.9 %, p = 0.006). Generally, CT positivity rate declined with increasing number of prior negative CTs. CT positivity rate was significantly higher in 100 patients undergoing single CT versus 155 patients undergoing repeat CTs (46.5 vs. 6.5 %, p = 0.0001). Positive repeat CT findings included intestinal mural thickening/mass (7), colitis (5), appendicitis (4), and other (14). Among 15 analyzed clinical parameters, two significantly predicted repeat CT positivity, namely, leukocytosis (p = 0.03) and APACHE-II-score >5 (p = 0.01). Repeat CTs constituted 47 % of all CTs.

Conclusions

Repeat abdominal CT after initially negative CT(s) performed for nontraumatic abdominal pain has a low diagnostic yield. Leukocytosis and APACHE-II score might help predict CT scan positivity. Data suggest restricted abdominal CT utilization in ER patients with multiple prior negative CTs. Findings warrant confirmation in prospective studies.     

Serum Proteomic Patterns as a Predictor of Severity in Acute Pancreatitis

Background:Approximately 20% of patients with acute pancreatitis (AP) develop a severe and potentially life-threatening course. Serum proteomic pattern analysis for disease diagnosis is a promising novel and rapidly expanding field based on the hypothesis that serum patterns of low molecular mass biomarkers can specifically reflect an underlying organ-specific pathologic state.Aim:To evaluate the potential differences in proteomic profiles between patients with mild and severe AP. Methods: Sera from 21 patients with mild AP and 7 patients with severe AP were analyzed using surface-enhanced laser desorption/ionizationtime-of-flight mass spectrometry (SELDI-TOF MS). Samples were profiled in duplicate on IMAC3 ProteinChips® arrays. Results: Of 79 spectral peak clusters (classifiers) detected, 18 had significantly different signal intensities between mild AP (MAP) and severe AP (SAP) sera (p < 0.01; Mann-Whitney U test, averaging for technical replicates) and were considered as potential classifiers in classification and regression tree (CART) analysis. The CART analysis returned simple classification trees consisting ofone primary splitter, at 11, 720 Da. Training data performance delivered nearly 100% sensitivity and 81% specificity for discrimination of SAP. The next top performing classifier was indicated at 4,283 Da m/z peak. Conclusions:These initial data suggest that serum proteomic profiles contain features that discriminate MAP and SAP. Larger sample sizes will be required for the development and validation of more specific predictive algorithms.     

Prognostic Value of Endoscopic Ultrasound in Acute Pancreatitis

Background/Aims: Endoscopic ultrasonography (EUS) is a useful modality to diagnose causes of pancreatitis. The role of EUS for prediction of pancreatitis severity has not been studied. The aim of this study was to identify the utility of EUS in determining the severity of acute pancreatitis (AP). Methods: All patients diagnosed with pancreatitis consecutively underwent EUS on the 2nd day of their admission. Atlanta criteria were used as the severity index of pancreatitis. Results: During the study period, 114 patients (74 females, 40 males; mean age of 53.03 ± 17.7 years) were enrolled in the study. The most common cause of AP was gallstone (78.9%). According to the Atlanta criteria, pancreatitis was mild in 72 (63.2%) and severe in 42 (36.8%) patients. In univariate analysis, the presence of peri pancreatic edema, pancreas inhomogeneity, common bile duct dilation and ascites were associated with severe pancreatitis. In multivariate analysis, only the presence of peri pancreatic edema in EUS correlated with the severity of AP according to the Atlanta criteria (sensitivity, specificity and accuracy: 65.8, 75.7 and 72.2%, respectively). Conclusion: EUS may be a new useful imaging modality for prediction of severity of AP and may have prognostic significance in the early phase of AP.     

Early Prediction of Severity in Acute Pancreatitis Using Infrared Spectroscopy of Serum

Background: One of the main problems in the management of acute pancreatitis (AP) is the scarcity of accurate predictors of disease severity. Methods: In a prospective design, we compared APACHE II score, C-reactive protein (CRP) level, and infrared (IR) spectral absorption of serum (wavelength 940 nm) in 167 consecutive patients with AP, 34 with predicted severe and 133 with mild form. Results: The IR spectral absorption levels on admission and at 24 h after admission were significantly (p< 0.05) lower in patients with severe AP. On admission, the sensitivity was 74, 56, and 44%; the specificity was 82, 83, and 81%; the positive predictive value was 51, 45, and 37%, and the negative predictive value was 92, 88, and 85%, for IR spectroscopy, APACHE II, and CRP, respectively. At 24 h, the sensitivity, specificity, positive predictive value, and negative predictive value was 82, 74, 44, and 94%; 65, 72, 37, and 89%; 68, 73, 39, and 90%, for IR spectroscopy, CRP, and APACHE II, respectively. Conclusions: IR spectroscopy seems to be useful for early detection of severe AP and, in turn, for identifying patients requiring treatment in the intensive care unit and who can benefit from novel therapies.     

Protease Activation,Pancreatic Leakage,and Inflammation in Acute Pancreatitis: Differences between Mild and Severe Cases and Changes over the First Three Days

Background/Aims: The pathophysiology of acute pancreatitis (AP) may be studied using markers of protease activation (active carboxypeptidase B (aCAP), the activation peptide of carboxypeptidase B (CAPAP)), leakage of pancreatic enzymes (trypsinogen-2, procarboxypeptidase B (proCAP), amylase), and inflammation (monocyte chemoattractant protein-1 (MCP-1), CRP).Methods: This prospective study included 140 cases of AP. Mild (n = 124) and severe (n = 16) cases were compared with respect to serum levels of trypsinogen-2, proCAP, amylase, aCAP, CAPAP (serum/urine), MCP-1 (serum/urine) and CRP on days 1, 2 and 3 from onset of symptoms. All patients with information on all 3 days were included in a time-course analysis (n = 44-55, except amylase: n = 27). Results: High levels in severe versus mild cases were seen for trypsinogen-2, CAPAP in serum and urine, and MCP-1 in serum on days 1–3. No differences were seen for proCAP, amylase and aCAP. MCP-1 in urine was significantly elevated on day 1–2, and CRP on day 2–3. CAPAP and MCP-1 levels peaked early and stayed elevated for 48 h in serum. Conclusion: Protease activation and inflammation are early events in AP, with high levels of these markers within 24 h. Protease activation declines after 48 h, whereas inflammation is present for a longer time.     

Galanin Receptor Antagonist M35 but Not M40 or C7 Ameliorates Cerulein-Induced Acute Pancreatitis in Mice

Background/Aims: We compared the galanin antagonists C7, M35, M40 and galantide, for their ability to ameliorate acute pancreatitis (AP). Methods: Galanin antagonists were co-administered with 7 hourly cerulein injections used to induce AP. Plasma amylase and lipase activities were measured as indices of AP, and pancreata were harvested at 12 h for histological examination and estimation of myeloperoxidase (MPO) activity. Results: Treatment with galantide, M35 and C7 ameliorated the AP-induced plasma hyperenzymemia by 40–75%. Administration of M40 did not significantly alter plasma hyperenzymemia. Galantide, M35 and M40 significantly reduced the pancreatic MPO activity by 65–80%, whereas C7 increased MPO activity. Galantide and M35 but not C7 or M40 treatment significantly reduced the AP-induced necrosis score by 30–50% compared to the AP alone group. C7 alone increased plasma lipase activity and the pancreatic necrosis score compared with saline treatment alone, whereas the other antagonists were without effect. Conclusion: Galantide and M35 ameliorated the severity of AP, but M40 and C7 had mixed effects. Complex galanin pathways may be involved in cerulein-induced AP. M35 and galantide are potential therapeutic peptides for the treatment of AP and further evaluation should be considered.     

Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied?

Background and aimRevision of the Atlanta classification for acute pancreatitis (AP) was long awaited. The Revised Atlanta Classification has been recently proposed. In this study, we aim to prospectively evaluate and validate the clinical utility of the new definitions.Patient and methods163 consecutive patients with AP were followed till death/6 mths after discharge. AP was categorized as mild (MAP) (no local complication[LC] and organ failure[OF]), moderate (MSAP)(transient OF and/or local/systemic complication but no persistent OF) and severe (SAP) AP (persistent OF). LC included acute peripancreatic fluid collections, pseudocyst, acute necrotic collection, walled-off necrosis, gastric outlet dysfunction, splenic/portal vein thrombosis, and colonic necrosis. Baseline characteristics (age/gender/hematocrit/BUN/SIRS/BISAP) and outcomes (total hospital stay/need for ICU care/ICU days/primary infected (peri)pancreatic necrosis[IN]/in-hospital death) were compared.Results43 (26.4%) patients had ANP, 87 (53.4%) patients had MAP, 58 (35.6%) MSAP and 18 (11.04%) SAP. Among the baseline characteristics, BISAP score was significantly higher in MSAP compared to MAP [1.6 (1.5–2.01) vs 1.2 (1.9–2.4); p = 0.002]; and BUN was significantly higher in SAP compared to MSAP[64.9 (50.7–79.1) vs 24.9 (20.7–29.1); p < 0.0001]. All outcomes except mortality were significantly higher in MSAP compared to MAP. Need for ICU care (83.3%vs43.1%; p = 0.01), total ICU days[7.9 (4.8–10.9) vs 3.5 (2.7–5.1); p = 0.04] and mortality (38.9%vs1.7%; p = 0.0002) was significantly more in SAP compared to MSAP. 8/18 (44.4%) patients had POF within seven days of disease onset (early OF). This was associated with 37.5% of total in-hospital mortality. Patients with MSAP who had primary IN (n = 10) had similar outcomes as SAP.ConclusionsThis study prospectively validates the clinical utility of the Revised Atlanta definitions of AP. However, MSAP patients with primary infected necrosis may behave as SAP. Furthermore, patients with early severe acute pancreatitis (early OF) could represent a subgroup that needs to be dealt with separately in classification systems.     

Useful Markers for Predicting Severity and Monitoring Progression of Acute Pancreatitis

Background: The main problem in staging acute pancreatitis is the lack of accurate predictors of disease severity and of markers for progression of acute pancreatitis.Methods: We reviewed the literature for all candidate markers of acute pancreatitis and graded their usefulness and practicability for prediction of severe pancreatitis and for monitoring disease progression.Results: Several markers can differentiate mild and severe cases of acute pancreatitis with a high positive predictive value. Trypsinogen activation peptide and procalcitonin show significant differences in patients with mild and severe disease already on admission. While most parameters peak early and decrease rapidly thereafter, C-reactive protein (CRP), phospholipase A ₂ , procalcitonin and serum amyloid A are reliable predictors with persistently elevated levels in severe disease. CRP is still the reference parameter of all predictors indicating severe disease and pancreatic necrosis. So far, no single parame-ter has been developed which is suitable for early prediction of infected pancreatic necrosis.Conclusion: Of all markers available today, CRP is the 'gold standard' in predicting the severity of acute pancreatitis, but procalci-tonin seems to be a promising tool to monitor the progression of the disease. CRP has already been established in clinical routine. For procalcitonin, a practicable assay is also available and could easily be adopted into clinical routine.     

Acute Pancreatitis Classifications: Basis and Key Goals

To explore the efficacy of the revised Atlanta classification (RACAP) and the determinant-based classification of acute pancreatitis severity (DBCAPS) on the basis of clinical data and feedback from patients with acute pancreatitis (AP).The authors retrospectively investigated a total of 573 patients with AP admitted to our hospital between December 2011 and December 2014. The definitions of severity and local complications in AP using RACAP and DBCAPS are presented and common points and mutual differences between the 2 groups are analyzed and discussed.Classification according to RACAP and DBCAPS found 86 (15%) and 178 (31.1%) mild cases (P < 0.01), 269 (46.9%) and 176 (30.7%) moderate cases (P < 0.01), and 218 (38.0%) and 219 (38.2%) severe cases (P = 0.95), respectively. A major contribution of DBCAPS is the introduction of a new type of severe AP, critical AP, identified in 4 patients (0.7%). Complications were observed in 313 RACAP-defined cases and 153 DBCAPS-defined cases (P < 0.01). Among the 313 RACAP-defined cases, acute peripancreatic fluid collection (236 patients, 75.40%), pancreatic pseudocysts (20 patients, 6.4%), acute necrotic collection (42 patients, 13.4%), and walled-off necrosis (15 patients, 4.8%) were observed. Among the 153 DBCAPS-defined cases, sterile peripancreatic necrosis (105 patients, 68.6%), sterile pancreatic necrosis (44 patients, 28.8%), infected peripancreatic necrosis (2 patients, 1.3%), and infected pancreatic necrosis (2/153 patients, 1.3%) were observed.Both classifications adopted organ failure and complications as determinants of severity. Revised Atlanta classification refined local complications and DBCAPS modified severity to include critical AP. In accordance with the demands of precision medicine, a combination of the 2 could be important for further clinical practice and scientific research.     

Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis

AIM: To study the safety of epidural anesthesia(EA),its effect on pancreatic perfusion and the outcome of patients with acute pancreatitis(AP).METHODS: From 2005 to August 2010,patients with predicted severe AP [Ranson score ≥ 2,C-reactive protein 100 or necrosis on computed tomography(CT)] were prospectively randomized to either a group receiving EA or a control group treated by patientcontrolled intravenous analgesia. Pain management was evaluated in the two groups every eight hours using the visual analog pain scale(VAS). Parameters for clinical severity such as length of hospital stay,use of antibiotics,admission to the intensive care unit,radiological/clinical complications and the need for surgical necrosectomy including biochemical data were recorded. A CT scan using a perfusion protocol was performed on admission and at 72 h to evaluate pancreatic blood flow. A significant variation in blood flow was defined as a 20% difference in pancreatic perfusion between admission and 72 h and was measured in the head,body and tail of the pancreas.RESULTS: We enrolled 35 patients. Thirteen were randomized to the EA group and 22 to the control group. There were no differences in demographic characteristics between the two groups. The Balthazar radiological severity score on admission was higher in the EA group than in the control group(mean score 4.15 ± 2.54 vs 3.38 ± 1.75,respectively,P = 0.347) and the median Ranson scores were 3.4 and 2.7 respectively(P = NS). The median duration of EA was 5.7 d,and no complications of the epidural procedure were reported. An improvement in perfusion of the pancreas was observed in 13/30(43%) of measurements in the EA group vs 2/27(7%) in the control group(P = 0.0025). Necrosectomy was performed in 1/13 patients in the EA group vs 4/22 patients in the control group(P = 0.63). The VAS improved during the first ten days in the EA group compared to the control group(0.2 vs 2.33,P = 0.034 at 10 d). Length of stay and mortality were not statistically different between the 2 groups(26 d vs 30 d,P = 0.65,and 0% for both respectively).CONCLUSION: Our study demonstrates that EA increases arterial perfusion of the pancreas and improves the clinical outcome of patients with AP.     

CT严重指数、超声造影联合血清降钙素原评估AP疗效

背景超声具有无创简便等优点,在急性胰腺炎病诊治中发挥着重要作用,而超声造影能通过分析胰腺微循环血流灌注,评估其缺血坏死状态,为临床诊治提供血流动力学信息.目的探讨超声造影联合血清降钙素原(procalcitonin,PCT)在评估急性胰腺炎(acute pancreatitis,AP)病情和疗效中的应用价值,及其与CT严重指数(CT severity indices,CTSI)的相关性.方法选取在我院接受治疗的AP患者作为研究对象,共63例,其中轻症AP患者38例(轻症AP组),重症AP患者25例(重症AP组).所有患者治疗前后测定血清PCT水平,行胰腺超声造影及腹部多层螺旋CT检查,记录超声造影严重指数(ultrasound severity indices,USSI)及CTSI,分析超声造影联合PCT评估疗效的可行性.结果超声造影诊断轻症AP患者37例,重症AP患者26例,敏感度=92.00%(23/25),特异度=92.11%(35/38);准确率=92.06%(58/63);重症AP组的血清PCT水平、USSI及CTSI明显高于轻症AP组,差异均有统计学意义(P<0.05);不同治疗结局组间的血清PCT水平、USSI及CTSI比较,差异均有统计学意义(P<0.05);治疗后患者血清PCT水平、USSI分别与CTSI呈正相关(r=0.803,0.951,均P<0.05);治疗后患者血清PCT水平、USSI分别与临床疗效呈负相关(r=-0.721,-0.836,均P<0.05).结论超声造影能有效显示胰腺组织缺血坏死状态,准确反映AP病情,联合血清PCT水平可为临床全面准确评估AP病情及预后提供有价值的参考.     

Factors Predicting Mortality in Severe Acute Pancreatitis

Acute pancreatitis (AP) is a common disorder in which ensuing serious complications may lead to a fatal outcome in patients. Background/Aims: To describe a large series of patients with severe AP (SAP) who were admitted to our hospital and to identify factors predicting mortality.Patients and Methods: In a retrospective study, all patients with SAP diagnosed between February 1996 and October 2000 according to the Atlanta criteria were studied.Results: Out of a total of 363 AP patients, 67 developed SAP. The mean age of the patients was 69; the commonest etiology was biliary; 55.2% developed necrosis; the commonest systemic complication was respiratory failure (44.7%), followed by acute renal failure (35.8%) and shock (20.9%). A total of 31.3% of the patients died. Factors significantly related to mortality were age, upper digestive tract bleeding, acute renal failure, respiratory failure and shock by univariate analysis. However, pseudocysts seemed to have a protective effect. By multivariate analysis, independent prognostic factors were age, acute renal failure and respiratory failure.Conclusions: Patients with SAP mainly died due to systemic complications, especially acute renal failure and respiratory failure. Necrosis (in the absence or presence of infection) was not correlated with increased mortality. A pseudocyst was found to be a protective factor, probably because the definition itself led to the selection of patients who had survived multiorgan failure.