Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage

AIM： To study retrospectively the influence of intra-abdominal hypertension （IAH） and abdominal compartment syndrome （ACS） in patients with early acute pancreatitis （AP） （during the first week after admission） on physiological functions, and the association of the presence of IAH/ACS and outcome.
METHODS： Patients （n = 74） with AP recruited in this study were divided into two groups according to intra-abdominal pressure （IAP） determined by indirect measurement using the transvesical route via Foley bladder catheter during the first week after admission. Patients （n = 44） with IAP ≥ 12 mmHg were assigned in IAH group, and the remaining patients （n = 30） with IAP 〈 12 mmHg in normal IAP group. For analysis of the influence of IAH/ACS on organ function and outcome, the physiological parameters and the occurrence of organ dysfunction during intensive care unit （ICU） stay were recorded, as were the incidences of pancreatic infection and in-hospital mortality.
RESULTS： IAH within the first week after admission was found in 44 patients （59.46%）. Although the APACHE Ⅱ scores on admission and the Ranson scores within 48 h after hospitalization were elevated in IAH patients in early stage, they did not show the statistically significant differences from patients with normal IAP within a week after admission （16.18 ± 3.90 vs 15.70 ± 4.25, P = 0.616; 3.70 ± 0.93 vs 3.47 ± 0.94, P = 0.285, respectively）. ACS in early AP was recorded in 20 patients （27.03%）. During any 24-h period of the first week after admission, the recorded mean IAP correlated significantly with the Marshall score calculated at the same time interval in IAH group （r = 0.635, P 〈 0.001）. Although ACS patients had obvious amelioration in physiological variables within 24 h after decompression, the incidences of pancreatitic infection, septic shock, multiple organ dysfunction syndrome （MODS） and death in the patients with ACS were significantly higher than that in other patients wit     

Treatment of abdominal compartment syndrome in severe acute pancreatitis patients with traditional Chinese medicine

AIM： To investigate the therapeutic effect of traditional Chinese traditional medicines Da Cheng Qi Decoction （Timely-Purging and Yin-Preserving Decoction） and Glauber＇s salt combined with conservative measures on abdominal compartment syndrome （ACS） in severe acute pancreatitis （SAP） patients.
METHODS： Eighty consecutive SAP patients, admitted for routine non-operative conservative treatment, were randomly divided into study group and control group （40 patients in each group）. Patients in the study group received Da Cheng Qi Decoction enema for 2 h and external use of Glauber＇s salt, once a day for 7 d. Patients in the control group received normal saline （NS） enema. Routine non-operative conservative treatments included non-per os nutrition （NPON）, gastrointestinal decompression, life support, total parenteral nutrition （TPN）, continuous peripancreatic vascular pharmaceutical infusion and drug therapy. Intra-cystic pressure （ICP） of the two groups was measured during treatment. The effectiveness and outcomes of treatment were observed and APACHE Ⅱ scores were applied in analysis.
RESULTS： On days 4 and 5 of treatment, the ICP was lower in the study group than in the control group（P 〈 0.05）. On days 3-5 of treatment, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） scores for the study and control groups were significantly different （P 〈 0.05）. Both the effectiveness and outcome of the treatment with Da Cheng Qi Decoction on abdominalgia, burbulence relief time, ascites quantity, cyst formation rate and hospitalization time were quite different between the two groups （P 〈 0.05）. The mortality rate for the two groups had no significant difference.
CONCLUSION： Da Cheng Qi Decoction enema and external use of Glauber＇s salt combined with routine non-operative conservative treatment can decrease the intra-abdominal pressure （IAP） of SAP patients and have preventive and therapeutic effects on abdominal compartment syndrome o     

Continuous regional arterial infusion and laparotomic decompression for severe acute pancreatitis with abdominal compartment syndrome

AIM:To evaluate the therapeutic effects of abdominal decompression plus continuous regional arterial infusion(CRAI) via a drug delivery system(DDS) in severe acute pancreatitis(SAP) patients with abdominal compartment syndrome(ACS).METHODS:We presented our recent experience in 8 patients with SAP.The patients developed clinical ACS,which required abdominal decompression.During the operation,a DDS was inserted into the peripancreatic artery(the catheter was inserted from the right gastroepiploic artery until...     

Ascites in acute pancreatitis: not a silent bystander

Background & aimAscites in patients with acute pancreatitis (AP) is understudied although recent literature hints at its evident role in the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome.MethodsConsecutive patients of AP were studied and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites.ResultsOf the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p = 0.001), necrosis (p=<0.001) and higher severity assessment scores. The ascites group had significantly longer hospital and ICU stay and higher ventilator days compared to the non-ascites group. Mortality was also higher in the ascites group (34.1% vs 8.45; p = 0.001). Majority of patients with ascites had moderate to gross ascites (75.6%), low serum ascites albumin gradient (87.8%) with low amylase levels (71.9%). Sub-group analysis in ascites group showed that patients with fatal outcome had higher rates of moderate to gross ascites, higher baseline IAP and lower reduction in IAP after 48 h. Moderate to gross ascites and grades of intra-abdominal hypertension (IAH) were significant predictors of mortality (AUC – 0.76).ConclusionAP patients with ascites have a more severe disease with poorer outcome. Higher degrees of ascites and IAH grades are significant predictors of mortality.     

Indwelling catheter and conservative measures in the treatment of abdominal compartment syndrome in fulminant acute pancreatitis

AIM: To study the effect of combined indwelling catheter, hemofiltration, respiration support and traditional Chinese medicine (e.g. Dahuang) in treating abdominal compartment syndrome of fulminant acute pancreatitis. METHODS: Patients with fulminant acute pancreatitis were divided randomly into 2 groups of combined indwelling catheter celiac drainage and intra-abdominal pressure monitoring and routine conservative measures group (group 1) and control group (group 2). Routine non-operative conservative treatments including hemofiltration, respiration support, gastrointestinal TCM ablution were also applied in control group patients. Effectiveness of the two groups was observed, and APACHE II scores were applied for analysis. RESULTS: On the second and fifth days after treatment, APACHE II scores of group 1 and 2 patients were significantly different. Comparison of effectiveness (abdomi-nalgia and burbulence relief time, hospitalization time) between groups 1 and 2 showed significant difference, as well as incidence rates of cysts formation. Mortality rates of groups 1 and 2 were 10.0% and 20.7%, respectively. For patients in group 1, celiac drainage quantity and intra-abdominal pressure, and hospitalization time were positively correlated (r = 0.552, 0.748, 0.923, P < 0.01) with APACHE II scores. CONCLUSION: Combined indwelling catheter celiac drainage and intra-abdominal pressure monitoring, short veno-venous hemofiltration (SVVH), gastrointestinal TCM ablution, respiration support have preventive and treatment effects on abdominal compartment syndrome of fulminant acute pancreatitis.     

肝移植术后腹腔高压致腹腔间隔室综合征2例

腹腔高压可导致多器官功能障碍甚至衰竭,演进成致死性腹腔间隔室综合征.肝移植存在导致腹腔高压的多种病理因素,一旦形成腹腔间隔室综合征,预后极差.本文报道肝移植术后腹腔间隔室综合征2例,结合文献资料对该病症进行分析讨论,以提高对该病症的认识,改善预后.     

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis – An opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.     

Abdominal compartment syndrome:Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome are well recognized entities among surgical patients.Nevertheless,a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units(ICU)and has been widely recognized as an independent risk factor for mortality.It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality.Frequently it is underdiagnosed and undertreated in this patient population.Elevated intraabdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure.When intraabdominal hypertension is not promptly recognized and treated,it leads to abdominal compartment syndrome,multiorgan dysfunction syndrome and death.Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis,shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension.This article presents an overview of the epidemiology,definitions,risk factors,pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.     

Early complications after interventions in patients with acute pancreatitis

AIM: To identify the possible predictors of early complications after the initial intervention in acute necrotizing pancreatitis.METHODS: We collected the medical records of 334 patients with acute necrotizing pancreatitis who received initial intervention in our center. Complications associated with predictors were analyzed.RESULTS: The postoperative mortality rate was 16% (53/334). Up to 31% of patients were successfully treated with percutaneous catheter drainage alone. The rates of intra-abdominal bleeding, colonic fistula, and progressive infection were 15% (50/334), 20% (68/334), and 26% (87/334), respectively. Multivariate analysis indicated that Marshall score upon admission, multiple organ failure, preoperative respiratory infection, and sepsis were the predictors of postoperative progressive infection (P < 0.05). Single organ failure, systemic inflammatory response syndrome upon admission, and C-reactive protein level upon admission were the risk factors of postoperative colonic fistula (P < 0.05). Moreover, preoperative Marshall score, organ failure, sepsis, and preoperative systemic inflammatory response syndrome were the risk factors of postoperative intra-abdominal bleeding (P < 0.05).CONCLUSION: Marshall score, organ failures, preoperative respiratory infection, sepsis, preoperative systemic inflammatory response syndrome, and C-reactive protein level upon admission are associated with postoperative complications.     

Activated matrix metalloproteinase 8 in serum predicts severity of acute pancreatitis

ObjectivesSevere acute pancreatitis (SAP) has high morbidity and mortality but there are no widely accepted predictive biomarkers in clinical use. Matrix metalloproteinases (MMPs) are active in tissue destruction and inflammatory responses. We studied whether serum levels of activated MMP-8 (aMMP-8), MMP-9 and their regulators tissue inhibitor of matrix metalloproteinases (TIMP)-1, myeloperoxidase (MPO) and human neutrophil elastase (HNE) could predict the development of SAP.MethodsThe study comprised 214 AP patients (revised Atlanta classification: 142 mild, MAP; 54 moderately severe, MSAP; 18 SAP) referred to Helsinki University Hospital. A venous blood sample was taken within 72 h from the onset of symptoms. Serum levels of aMMP-8 were determined using immunofluorometric assay, and those of MMP-9, TIMP-1, MPO and HNE using enzyme-linked immunosorbent assay. AP groups were compared using Jonckheere-Terpstra test and predictive value for SAP was analyzed using receiver operating characteristics (ROC) analysis.ResultsSerum aMMP-8 levels were higher in SAP (median 657 ng/ml, interquartile range 542–738 ng/ml) compared to MSAP (358 ng/ml, 175–564 ng/ml; p < 0.001) and MAP (231 ng/ml, 128–507 ng/ml; p < 0.001). Similar trend was seen with TIMP-1 and MPO. In ROC analysis aMMP-8, MPO and TIMP-1 emerged as potential markers for the development of SAP (areas under ROC curves 0.83, 0.71 and 0.69, respectively).ConclusionsSerum aMMP-8 measured early in the course of AP (within 72 h of symptom onset) predicted the development of SAP.     

Síndrome compartimental abdominal: conceptos actuales y manejo

Abdominal compartment syndrome occurs when 2 or more anatomic compartments have a sustained intra-abdominal pressure > 20 mmHg, associated with organ failure. Incidence is 2% and prevalence varies from 0% to 36.4%.A literature search was conducted utilizing different databases. Articles published from 1970 to 2018 were included, in English or Spanish, to provide the concepts, classifications, and comprehensive management in the approach to abdominal compartment syndrome, for its treatment and the prevention of severe complications associated with the entity. Intravesical pressure measurement is the standard diagnostic method. Treatment is based on evacuation of the intraluminal content, identification and treatment of intra-abdominal lesions, improvement of abdominal wall compliance, and optimum administration of fluids and tissue perfusion. Laparotomy is generally followed by temporary abdominal wall closure 5 to 7 days after surgery. Reconstruction is performed 6 to 12 months after the last operation.Abdominal compartment syndrome should be diagnosed and operated on before organic damage from the illness occurs. Kidney injury can frequently progress and is a parameter for considering abdominal decompression. Having a biomarker for early damage would be ideal. Surgical treatment is successful in the majority of cases. A multidisciplinary focus is necessary for the intensive care and reconstructive needs of the patient. Thus, efforts must be made to define and implement strategies for patient quality of life optimization.     

Management of intra-abdominal hypertension in patients with severe acute pancreatitis with continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter

To evaluate, with a prospective observational study, whether continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter (PMMA-CHDF) is effective for prevention and treatment of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) on patients with severe acute pancreatitis (SAP). The study was carried out in the general intensive care unit (ICU) of a university hospital. Seventeen consecutive patients with SAP were treated in the intensive care unit and underwent PMMA-CHDF whether or not they had renal failure. Blood level of interleukin (IL)-6, as an indicator of cytokine network activation, and intra-abdominal pressure (IAP) were measured daily to investigate their time-course of changes and the correlation between the two. The blood level of IL-6 was high at 1350+/-1540 pg/mL on admission to the ICU. However, it significantly decreased to 679+/-594 pg/mL 24 h after initiation of PMMA-CHDF (P<0.05), and thereafter decreased rapidly. Mean intra-abdominal pressure (IAP) on admission was high, at 14.6+/-5.3 mm Hg, with an IAP of 20 mm Hg or over in 2 of 17 patients, showing that they had already developed IAH. The IAP was significantly lower (P<0.05) 24 h after initiation of PMMA-CHDF, and subsequently decreased. There was a significant positive correlation between blood level of IL-6 and IAP, suggesting that PMMA-CHDF improved vascular permeability through elimination of cytokines, and that it thereby decreased interstitial edema to lower IAP. Sixteen of the 17 patients were discharged from the hospital in remission from SAP without development of complications. Continuous hemodiafiltration using a polymethyl methacrylate membrane hemofilter appears to be effective for prevention and treatment of IAH in patients with SAP through the removal of causative cytokines of hyperpermeability.     

代谢综合征对急性胰腺炎患者预后的影响

目的 探讨代谢综合征对急性胰腺炎患者预后的影响。方法 回顾性分析2004年7月～2007年10月我院收治的起病时伴代谢综合征的急性胰腺炎19例（A组）和不伴代谢综合征的急性胰腺炎24例（B组），对两组腹部Balthazar CT分级评分、血CRP、血钙、血氧分压、腹痛缓解时间、禁食时间、血淀粉酶恢复时间、住院天数进行比较。结果 与B组相比，A组的Balthazar CT分级评分较高；血钙和血氧分压水平较低；A组的腹痛缓解时间、禁食时间、血淀粉酶恢复时间、住院天数明显长于B组。结论 代谢综合征与急性胰腺炎病情程度密切相关，代谢综合征可作为急性胰腺炎的预后因素。     

序贯通气对于急性胰腺炎所致急性呼吸窘迫综合征的临床效果

目的 研究序贯通气对于急性胰腺炎所致急性呼吸窘迫综合征的临床效果.方法 将我院ICU于2009年5月至2011年5月期间收治的72例由于急性胰腺炎所致的急性呼吸窘迫综合征患者作为研究对象,将所有患者按照随机分组原则分为治疗组(序贯通气组)与对照组(机械通气组),各36例,其中治疗组采用序贯通气法治疗,对照组采用普通机械通气法治疗.对比两组患者于治疗前、治疗后16h及拔管时PaO2、PaCO2、pH值以及无创通气时间、机械通气时间、死亡率、治愈率及不良反应发生率.结果 ①序贯通气组有创通气时间为(2.34±1.24)d,少于机械通气组有创通气时间[(5.21±2.32)d,t=3.230,P＜0.05];②序贯通气组总机械通气时间为(4.38±2.15)d,与机械通气组总机械通气时间[(4.25±2.35)d]比较差异无统计学意义(t=3.230,P＞0.05);③序贯通气组于治疗后16hpH平均值恢复正常,PaO2高于机械通气组(t=3.440,P＜0.05),PaCO2亦高于机械通气组(t=5.125,P＜0.05);④序贯通气组呼吸机相关性肺炎发生率为8.3％,低于机械通气组(16.7％,x2=15.644,P＜0.05);⑤序贯通气组治愈率(86.1％)高于机械通气组(75.0％),且不良反应发生率、死亡率均低于机械通气组.结论 使用有创-无创序贯通气治疗急性胰腺炎所致急性呼吸窘迫综合征,具有缩短有创通气时间、动脉血气水平恢复快、不良反应少、治愈率高等优点,值得于临床广泛推广使用.     

Peritoneal lavage with aprotinin in patients with severe acute pancreatitis

Summary Conclusion Although high-dose aprotinin given intraperitoneally to patients with severe acute pancreatitis seems to inhibit activated trypsin in the peritoneal cavity, the treatment has little effect on the balance between proteases and antiproteases. Plasma levels of leukocyte proteases were high in all the patients, indicating leukocyte activation to be an important feature of the pathophysiology of severe acute pancreatitis. A surprise finding was that the patients had higher peritoneal levels of pancreatic secretory trypsin inhibitor (PSTI) after the lavage procedure. Background Although most studies have shown protease inhibitor therapy to have little or no effect on acute pancreatitis, in an earlier study we found that very high doses of the protease inhibitor aprotinin given intraperitoneally to patients with severe acute pancreatitis seemed to reduce the need of surgical treatment for pancreatic necrosis. In the present study we have further analyzed plasma and peritoneal samples from the same patients to ascertain whether the aprotinin treatment affects the balance between proteases and endogenous antiproteases. Methods In a prospective double-blind randomized multicenter trial, 48 patients with severe acute pancreatitis were treated with intraperitoneal lavage. One group (aprotinin group,n=22) was also treated with high doses (20 million KIU given over 30 h) of aprotinin intraperitoneally. The remaining 26 patients made up the control group. The protease-antiprotease balance was studied by measuring immunoreactive anionic trypsin (irAT), cationic trypsin (irCT), complexes between cationic trypsin and alpha 1-protease inhibitor (irCT-α1PI), leukocyte elastase and neutrophil proteinase 4 (NP4), as well as the endogenous protease inhibitors, pancreatic secretory trypsin inhibitor (PSTI), alpha 2-macroglobulin (α 2M), alpha 1-protease inhibitor (α 1PI), antichymotrypsin (ACHY), and secretory leukocyte protease inhibitor (SLPI). Intraperitoneal levels were studied before and after the lavage procedure, and plasma levels were followed for 21 d. Results The control group had lower plasma levels of SLPI and analysis of peritoneal fluid showed the reduction of irCT-α 1PI to be more pronounced in the aprotinin group. None of the other variables measured differed significantly between the two groups. All patients had very high levels of leukocyte elastase and NP4 both in peritoneal exudate and in plasma. Peritoneal levels of PSTI were higher after the lavage procedure in contrast to the other measured variables that all showed lower peritoneal levels after the lavage.     

Abdominal compartment syndrome complicating primary percutaneous coronary intervention for acute myocardial infarction

A case is presented of iliac artery perforation during percutaneous coronary intervention. This resulted in retroperitoneal bleeding complicated by the development of the abdominal compartment syndrome and multi‐organ failure, which was successfully treated by abdominal decompression.     

Haemodynamic response to abdominal decompression in acute Budd–Chiari syndrome

Background: Intra‐abdominal hypertension (IAH) and abdominal compartment syndrome commonly occur in patients with liver disease. Aims: We compared haemodynamic variables pre‐ and post‐abdominal decompression in patients with acute Budd–Chiari syndrome (BCS) and patients with chronic liver disease (CLD), ascites and IAH. Methods: Patients with IAH admitted to the Liver ICU, King's College Hospital were studied. Transpulmonary thermodilution cardiac output (CO) monitoring was performed with the PiCCO^® system. Results: Ten patients with decompensated BCS (median age 39 years, 20–52) and eight patients with CLD (59 years, 33–65) and tense ascites requiring paracentesis were studied. Intra‐abdominal pressure (IAP) was raised in both groups pre‐intervention (BSC 23 mmHg, 17–40; CLD 26, 20–40). Intrathoracic blood volume (ITBVI) was persistently low in the BCS group (632 ml/m², 453–924) despite volume resuscitation. Post‐intervention, reduction in IAP was noted in both groups (BCS P<0.001, CLD P<0.0001). The ITBVI increased (P=0.001) in the BCS group only. An increase in cardiac index (CI) and stroke volume index (SVI) was noted in both groups (BCS: CI P=0.003, SVI: P=0.007; CLD: CI P=0.005, SVI P=0.02). The central venous pressure did not change in either group and did not correlate with markers of flow (CI, SVI) or IAP. Both groups demonstrated an inverse relationship between IAP, CI and SVI. Conclusion: Patients with BCS and IAH have evidence of central hypovolaemia. In addition to raised IAP, hepatic venous obstruction and caudate lobe hypertrophy limit venous return in patients with BCS. Reduction in IAP and re‐establishment of caval flow restores preload with improvement in CO.     

Acute limb ischemia due to abdominal compartment syndrome

Acute limb ischemia (ALI) is caused by embolisms or progressive atherosclerosis. We report the case of a 68‐year‐old female who presented with acute total occlusion of left iliac artery due to remarkably massive ascites from pancreatic cancer. To our knowledge, no other case reports of ALI caused by acute compartment syndrome have been published. We treated our case successfully by draining the ascites fluid without any balloon angioplasty or stent implantation. The removal of extrinsic compression may be the best treatment for cases of this type. © 2013 Wiley Periodicals, Inc.     

Pancreatic hemorrhage contributes to late mortality in patients with acute necrotizing pancreatitis

ObjectivesThe frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality.MethodsIn a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention.ResultsOut of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45–68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1–5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7–9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4–6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2–3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7–25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001].ConclusionPancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.