Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis.

The sensitivity of diagnostic serum amylase (greater than 1000 iu/l) was assessed in 417 patients with acute pancreatitis as a result of gall stones (258), alcohol (104), or miscellaneous causes (55), of whom 111 (27%) had a clinically severe attack (including 34 deaths). On hospital admission, an amylase value diagnostic of pancreatitis was found in 96.1% of all mild cases and in 87.4% of severe cases (p less than 0.001); at 48 hours these values were 33.3% and 48.2% respectively (p = 0.026). Diagnostic amylase levels for alcoholic patients were found in 86% of mild cases on admission and in 76% of severe cases (p less than 0.001, compared with other groups). The diagnostic levels were also significantly lower at 24 hours for both the alcoholic and miscellaneous groups compared with the gall stone group (p less than 0.001). Eight of 27 (30%) patients with a serum amylase activity less than 1000 iu/l had pancreatic necrosis compared with 12 of the remaining 390 (3.1%) patients (p less than 0.001); the mortality was also significantly different (44% v 5.6% respectively, p less than 0.001). These data support the view that more sensitive tests for acute pancreatitis are needed for routine use especially in those whose disease has an alcoholic aetiology.     

Epidemiology, aetiology and outcome of acute and chronic pancreatitis: An update

Over the past decades several epidemiological studies have been published reporting on incidence trends, hospital admissions, etiological factors and outcome of both acute and chronic pancreatitis. Over time, the incidence of acute pancreatitis has increased in the Western countries. Also, the number of hospital admissions for both acute and chronic pancreatitis have increased. These upward time trends possibly reflect a change in the prevalence of main etiological factors (e.g. gallstones and alcohol consumption) and cofactors such as obesity and genetic susceptibility. Acute and chronic pancreatitis are associated with significant morbidity and mortality and a substantial use of health care resources. Although the case-fatality rate of acute pancreatitis decreased over time, the overall population mortality did not change for both acute and chronic pancreatitis. This chapter will focus on recent developments in the epidemiology, aetiology, natural course and outcome of both acute and chronic pancreatitis.     

Response and outcome from fluid resuscitation in acute pancreatitis: a prospective cohort study

Background

Intravenous (IV) fluid resuscitation remains the cornerstone for early management of acute pancreatitis (AP), but many questions remain unanswered, including how to determine whether patients will benefit from additional fluids. The aim was to investigate the utility of serum biomarkers of responsiveness IV fluid resuscitation in patients with AP and systemic inflammatory response syndrome (SIRS).

Influence of obesity on the severity and clinical outcome of acute pancreatitis

Background/Aims

Obesity tends to be associated with increased mortality and morbidity in acute pancreatitis. However, in Asian populations, higher morbidity and mortality have been reported in patients with low body mass indexes (BMIs). This study was undertaken to evaluate the relation between obesity and outcome, and to investigate the occurrence of complications by overweightedness in acute pancreatitis.

Methods

The medical records of 403 patients with acute pancreatitis were reviewed retrospectively, and Ranson''s scores, modified Glasgow scores, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and computed tomography severity indexes were calculated. Patients were categorized by BMI for the analysis.

Results

When compared with normal patients (BMI 18.5 to 22.9), all categories with a BMI ≥23 had an increased risk of developing a severe form of acute pancreatitis (p=0.003) and all categories with a BMI ≥25 significantly predicted severity (p<0.001). Patients with class 1 obesity (BMI 25 to 29.9) developed significantly more systemic and metabolic complications.

Conclusions

Overweightedness and obesity were found to be associated with a higher risk of developing severe pancreatitis. Further studies are needed to establish the precise prognostic value of obesity in members of the population with low BMIs.     

A systematic review and meta-analysis of the aetiology of acute pancreatitis

Background

Gallstones and alcohol are currently the most frequent aetiologies of acute pancreatitis (AP). The aim of this study is to quantify these aetiologies worldwide, by geographic region and by diagnostic method.

Coxsackie and mumpsvirus infection in a prospective study of acute pancreatitis.

A prospective study of 116 patients with acute pancreatitis included routine screening for evidence of viral infection. Five patients (all female) exhibited significant rising antibody titres to Coxsackie B or mumpsvirus, while none of the remaining 111 patients did. Diarrhoea was a prodromal feature of the pancreatitis in those patients with evidence of viral disease. Screening patients with acute pancreatitis for Coxsackie B and mumpsvirus infections is worthwhile in the identification of aetiological factors and may minimise protracted biliary investigations. The incidence of "idiopathic" acute pancreatitis in this study was 5-2% (six patients).     

Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study

BACKGROUND: To assess the analgesic efficacy and side effects of buprenorphine and procaine in patients with acute pancreatitis. METHODS: Forty patients (average age, 50 years; 23 male) with acute pancreatitis or an acute bout of a chronic pancreatitis were prospectively randomized to receive buprenorphine or procaine for pain relief. Both analgesics were administered as constant intravenous (i.v.) infusions and additional analgesics were given on demand. Pain scores were assessed on a visual analogue scale. Close clinical control and laboratory checks were performed during the three-day study period. RESULTS: Patients receiving buprenorphine were significantly less likely to demand additional analgesics (1 versus 14 patients; P < 0.0001). The pain scores for patients in the buprenorphine group were significantly lower over the treatment period in comparison to procaine (P < 0.05). The reduction of pain score was significantly greater during the initial two treatment days using buprenorphine (day 1: 55 versus 25, P < 0.0001; day 2: 62 versus 40, P = 0.005). Side effects were comparable for both groups with the exception of a slightly higher sedation rate under buprenorphine. CONCLUSIONS: Constant i.v. application of buprenorphine is more effective than the recommended procaine for pain relief in acute pancreatitis.     

BISAP评分对急性胰腺炎严重程度及预后评估的临床价值

目的 通过与传统的急性胰腺炎(AP)病情评分系统比较,了解急性胰腺炎严重程度床边指数(BISAP)评分对AP严重程度及预后评估的临床价值.方法 回顾性分析2005年1月至2010年12月间收治的497例AP患者资料,分别进行BISAP、APACHEⅡ、Ranson及Balthazar CT( CTSI)评分,评估病情严重程度.应用受试者工作曲线下面积(AUC)比较BISAP评分与其他各评分系统对AP严重程度及胰腺坏死、器官功能衰竭、患者病死发生的预测能力.结果 497例患者中重症急性胰腺炎(SAP) 101例,轻症急性胰腺炎(MAP) 396例,MAP组和SAP组患者的年龄、性别、病因分布差异无统计学意义.497例患者的BISAP评分、APACHEⅡ评分、Ranson评分的平均分值分别为(1.08±1.01)、(5.79±4.00)、(1.69±1.59)分,两两相关(r值分别为0.612、0.568、0.577,P值均＜0.001).此外,SAP患者的BISAP评分、APACHEⅡ评分、Ranson评分的分值均显著大于MAP患者(P值均＜0.01).BISAP评分预测SAP的AUC值为0.762( 95％ CI 0.722～0.799),阳性截止(cutoff)值为2分,敏感性、特异性、阳性预测值、阴性预测值分别为63.4％、83.1％、48.1％、89.4％;预测胰腺坏死的AUC值为0.711(95％CI0.612～0.797),cutoff值为2分,敏感性、特异性、阳性预测值、阴性预测值分别为84.6％、46.7％、35.5％、89.7％;预测器官衰竭的AUC值为0.777(95％ CI0.683 ～0.854),cutoff值为2分,敏感性、特异性、阳性预测值、阴性预测值分别为93.1％、51.4％、43.5％、94.9％;预测患者病死的AUC值为0.808(95％ CI 0.718 ～0.880),cutoff值为3分,敏感性、特异性、阳性预测值、阴性预测值分别为83.3％、67.4％、25.6％、96.8％.BISAP评分与其他评分系统预测SAP各预后指标的差异均无统计学意义.结论 BISAP评分对AP严重程度及预后的评估价值与其他传统的评分系统相同,但其只有5项指标,且均可在入院24h内采集,可以早期、简便地预测SAP,值得在临床推广应用.     

Early diagnosis and prediction of severity in acute pancreatitis using the urine trypsinogen-2 dipstick test： A prospective study

AIM： To evaluate the use of the trypsinogen-2 dipstick （Actim Pancreatitis） test for early diagnosis and prediction of severity in acute pancreatitis （AP）. METHODS： Ninety-two patients with AP were included in this study. The control group was 25 patients who had acute abdominal pain from non-pancreatic causes. Urine trypsinogen-2 dipstick test （UTDT） and conventional diagnostic tests were performed in all patients. Patients were divided by the Atlanta classification into two groups as having mild or severe pancreatitis. RESULTS： UTDT was positive in 87 （94.6%） of the AP patients and in two （8%） controls （P 〈 0.05）. Positive UTDT was found in 61 （92.4%） of 66 （71.7%） patients with mild pancreatitis and in all （100%） of the 26 （28.3%） with severe pancreatitis （P 〉 0.05）. UTDT positivity lasted longer in severe pancreatitis compared with that in mild pancreatitis （6.2 ＋ 2.5 d vs 2.0 ＋ 1.43 d, P 〈 0.05）. The sensitivity, specificity, positive predictive value, negative predictive value （NPV）, positive likelihood ratio （PLR） and negative likelihood ratio （NLR） of UTDT were 91%, 72%, 96.6%, 70.4%, 3.4 and 0.1, respectively. CONCLUSION： UTDT is a simple, rapid and reliable method for use on admission. It has high specificity and low NLR for early diagnosis and prediction of severity in AP. However, its relatively low NPV does not allow trypsinogen-2 dipstick test to be a stand-alone tool for diagnosis of acute pancreatitis; the use of other conventional diagnostic tools remains a requirement.     

Prognostic factors of critical acute pancreatitis: A prospective cohort study

BackgroundPatients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP.Aims & methodsThis was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors.ResultsOf the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5–18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2–54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3–15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5–8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2–10.1; p = 0.019) were significant factors.ConclusionAmong patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.     

Hypertriglyceridemia-induced acute pancreatitis: A prospective,multicenter, international cohort analysis of 716 acute pancreatitis cases

BackgroundHypertriglyceridemia is the third most common cause of acute pancreatitis (AP). It has been shown that hypertriglyceridemia aggravates the severity and related complications of AP; however, detailed analyses of large cohorts are contradictory. Our aim was to investigate the dose-dependent effect of hypertriglyceridemia on AP.MethodsAP patients over 18 years old who underwent triglyceride measurement within the initial three days were included into our cohort analysis from a prospective international, multicenter AP registry operated by the Hungarian Pancreatic Study Group. Data on 716 AP cases were analyzed. Six groups were created based on the highest triglyceride level (<1.7 mmol/l, 1.7–2.19 mmol/l, 2.2–5.59 mmol/l, 5.6–11.29 mmol/l, 11.3–22.59 mmol/l, ≥22.6 mmol/l).ResultsHypertriglyceridemia (≥1.7 mmol/l) presented in 30.6% of the patients and was significantly and dose-dependently associated with younger age and male gender. In 7.7% of AP cases, hypertriglyceridemia was considered as a causative etiological factor (≥11.3 mmol/l); however, 43.6% of these cases were associated with other etiologies (alcohol and biliary). Hypertriglyceridemia was significantly and dose-dependently related to obesity and diabetes. The rates of local complications and organ failure and maximum CRP level were significantly and dose-dependently raised by hypertriglyceridemia. Triglyceride above 11.3 mmol/l was linked to a significantly higher incidence of moderately severe AP and longer hospital stay, whereas triglyceride over 22.6 mmol/l was significantly associated with severe AP as well.ConclusionHypertriglyceridemia dose-dependently aggravates the severity and related complications of AP. Diagnostic workup for hypertriglyceridemia requires better awareness regardless of the etiology of AP.     

Hyperlipidemia in acute pancreatitis. Relationship with etiology, onset, and severity of the disease.

Serum lipid (triglycerides and cholesterol) concentrations were studied in 49 patients with acute pancreatitis (AP). The aims of the study were to investigate the prevalence of hyperlipidemia (HL) in patients with AP according to etiology and to evaluate whether HL precedes or is a consequence of AP. Moreover, we analyzed the relationship between HL and the development of pancreatic necrosis. At admission, 23 patients (47%) had HL: 9 of 19 patients with alcoholic pancreatitis, 5 of 18 patients with biliary pancreatitis, and 9 of 12 patients with AP of miscellaneous etiologies (p less than 0.05). Severe HL (serum triglycerides greater than 20 mmol/L) was observed in five patients. Serum lipid levels in patients with AP and HL decreased markedly during the first 72 h of evolution, but remained slightly above the upper normal limit in most of them after 15 d. The prevalence of HL was similar in edematous and necrotizing pancreatitis. Necrotizing pancreatitis was significantly associated with the presence of hypertriglyceridemia in conjunction with hypercholesterolemia (p less than 0.05). The observations that a) hyperlipidemia is an early event in acute pancreatitis, (b) serum lipid values decrease during the acute phase of the disease, (c) hyperlipidemia has a different prevalence in different etiologies, and (d) high serum lipid levels are not always associated to pancreatic necrosis suggest that HL is a preexistent metabolic abnormality with respect to AP. On the other hand, HL may play a role in aggravating AP.     

Renal doppler changes in patients with acute pancreatitis: A prospective study

BackgroundRenal Doppler to assess renal resistive index (RRI) is an attractive option to prognosticate acute kidney injury (AKI) in acute pancreatitis (AP) as it is feasible within scope of point-of-care ultrasound. However, RRI has been infrequently evaluated in AP.ObjectiveProspectively study diagnostic and prognostic performance of RRI in patients with AP.Methodology75 patients with AP were prospectively enrolled and followed till recovery/death. All patients were subjected to renal Doppler and RRI was compared between patients with and without AKI.ResultsThirty six patients developed AKI and 39 patients did not develop AKI. AKI network stage 1, 2 and 3 AKI was seen in 7(19.4%), 12(33.3%) and 17 (47.2%) patients respectively. Prognostic scoring done at admission by SIRS, modified marshal score, and BISAP scores, as well as duration of hospitalization and mortality rates were significantly higher in patients with AKI. Mean peak systolic velocity and RRI at upper, middle and lower poles of bilateral kidneys were comparable between patients with and without AKI. The RRI was abnormal in 46 (66.6%) patients and it was <0.6 in 35/46 (76%) and >0.7 in 11/46 (24%) patients respectively. RRI <0.6 was observed in 16 (53.3%) and 19 (48.7%) patients with and without AKI respectively (p = 0.80). RRI >0.7 was observed in 4 (53.3%) and 7 (48.7%) patients with and without AKI respectively (p = 0.74).ConclusionsAKI is associated with poor prognosis in AP. RRI on renal Doppler at admission seems to have poor diagnostic as well as prognostic performance for AKI in patients with AP.     

A prospective cohort study of the outcome of acute whiplash injury in Greece

OBJECTIVE: An earlier pilot study suggested that the late whiplash syndrome is uncommon in Greece. The purpose of the present study is to extend the evaluation to a larger sample, and include the prevalence of specific symptoms in the evaluation. METHODS: In a prospective, cohort study, a total of 180 accident victims were consecutively recruited following Emergency ward presentation. A standard questionnaire asked about neck pain, headache, shoulder pain, limb numbness or pain, and dizziness. Accident victims were followed for 6 months. RESULTS: In the initial 4 weeks after the accident, accident victims reported neck pain, headache, shoulder pain, arm numbness or pain, and dizziness, but at 4 weeks more than 90% had recovered from these, the remainder of the subjects having minor symptoms (not requiring therapy), and returning to their pre-accident state of health (which included minor symptoms). There were no cases of chronic disability. CONCLUSION: In Greece, symptoms after an acute whiplash injury are self-limiting, brief, and do not appear to evolve into the so-called late whiplash syndrome.