Biochemical identification of patients with gallstones associated with acute pancreatitis on the day of admission to hospital.

Current trends in the treatment of gallstone pancreatitis require rapid diagnosis of cholelithiasis. This study evaluates the diagnostic potential of plasma aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin on the day of admission to hospital in 215 attacks of acute pancreatitis. The optimal diagnostic cut-off level for AST was 60 IU/1. A transient elevation above 60 IU/1 was recorded in 111 (84.1%) of 132 attacks associated with gallstones, but in only 12 (14.5%) of 83 attacks without stones, and was unrelated to the severity of the attack. Elevated levels of alkaline phosphatase and bilirubin were also more common in attacks associated with gallstones but were less reliable for the identification of cholelithiasis than AST. As a sensitive indicator of hepatocyte disruption, the early and transient rise in plasma AST is consistent with the concept of transient ampullary obstruction in gallstone pancreatitis, and may be useful in identifying patients who require urgent surgical or endoscopic disimpaction.     

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.     

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.     

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.     

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.     

CT score and the severity of acute pancreatitis

The CT findings in 28 patients with acute pancreatitis were compared with the severity of the disease. The pancreatic image, which demonstrates the pancreatic lesion, was studied with respect to 9 items, and fluid accumulation showing the peripancreatic status with respect to 13 items. According to Forell's classification, the lesion was mild in 8 patients, moderate in 11, and severe in 9. The detection rates of abnormal pancreatic images and fluid accumulation increase with the advance in the severity of the disease. The mean CT score according to severity was 0.9 +/- 0.6 for mild pancreatitis, 7.2 +/- 4.5 for moderate pancreatitis, and 13.4 +/- 4.2 for severe pancreatitis. Significant differences were observed among the groups, suggesting that the CT score is useful for evaluating the severity of acute pancreatitis.     

Calcitonin gene-related peptide partially mediates nociception in acute experimental pancreatitis

BACKGROUND: The mechanism by which pancreatitis causes pain is unknown. The neuropeptide calcitonin gene-related peptide (CGRP) is released after sensory nerve activation and promotes nociceptive signaling in models of visceral pain. We hypothesized that acute pancreatitis leads to the activation of pancreatic sensory neurons that release CGRP in the dorsal horn of the spinal cord. This signal is ultimately transmitted to the brain, and pain is sensed. METHODS: To induce pancreatitis, rats were injected with l-arginine (500 mg/kg) intraperitoneally or saline (control). Pancreatitis was confirmed by measuring serum amylase and evaluating pancreatic histology. Activation of nociceptive pathways was evaluated by counting Fos-like immunoreactive nuclei (FLI) in the dorsal horn of the spinal cord at T3-L1. Some animals received the CGRP antagonist CGRP(8-37) (50 microg intrathecally) 2 hours before perfusion. Animals were compared using a 2-tailed t test. RESULTS: l-Arginine treatment induced acute necrotizing pancreatitis in the rat at 24 hours. l-Arginine (24 hours) increased FLI in the dorsal horn of the spinal cord, with a peak effect at L1. Intrathecal administration of CGRP(8-37) significantly decreased the number of FLI nuclei in the dorsal horn of the spinal cord in T11-L1. CONCLUSIONS: Nociception in the l-arginine model of acute pancreatitis is partially mediated by the release of CGRP in the dorsal horn of the spinal cord. Antagonism of CGRP or its receptors may be useful in treating pain from acute pancreatitis.     

Prognosis of the disease severity in patients with acute pancreatitis

Estimation of the severity state in patient, suffering an acute pancreatitis, while admitting him into a hospital, constitutes a significant part of diagnosis and complex treatment. Application of a highly accurate scales and markers, which are used to prognosticate the disease course severity and to determine the inflammation grade, may influence the results of complex treatment of the patients. In the investigation a high diagnostic accuracy in prognosis of an acute pancreatitis course severity was noted for APACHE II scale (24 hours) and Ranson scale (48 hours). There was established, that determination of a C-reactive protein content has less diagnostic accuracy, but it may be applied as a less complex and more rapid test for prognostication of an acute pancreatitis course severity after admitting the patient to hospital.     

The impact of oral feeding on the severity of acute pancreatitis

BACKGROUND: In the management of acute pancreatitis, oral feeding is prohibited and either enteral or parenteral feeding is commenced for the patients in an effort to not increase the secretion of the pancreatic enzymes. PURPOSE: This study was undertaken in an attempt to determine the impact of oral feeding on the severity of acute pancreatitis and to compare this impact with that of parenteral feeding. MATERIALS AND METHODS: Twenty-four female Sprague-Dawley rats were divided into two groups. In both groups, acute pancreatitis was induced by ligation of the main biliopancreatic duct. The rats in group I were fed orally and the rats in group II were fed parenterally. The rats were sacrificed at 48 hours, and blood samples were obtained from the heart upon exposure of the abdominal and thoracic cavities. The pancreas and the left lung were removed for histopathological examination. The levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT), glucose, calcium and blood urea nitrogen, base deficit, partial oxygen pressure, leukocyte count, and hematocrit level among Ranson criteria and the level of amylase were measured. The pancreas and the lung were examined under a light microscope. RESULTS: The levels of LDH, SGOT, and calcium for the rats in group I were significantly higher when compared with the rats in group II (P <0.05). Similarly, the levels of amylase for the rats in group I were found to be higher when compared with the rats in group II, but the difference was not significant. Inflammatory changes observed in the pancreas were less severe whereas inflammatory changes observed in the lung were more severe for the rats in group I when compared with the rats in group II. CONCLUSION: The blood levels of the enzymes were adversely affected for the rats fed orally. In contrast, inflammatory changes observed in the pancreas were more severe for the rats fed parenterally. The study suggests that certain hormones released from the duodenum upon stimulation by oral nutrient intake lessens the severity of pancreatitis through protective effects on the pancreas, whereas the elevated levels of the enzymes cause endothelial damage resulting in destruction in distant organs such as the lung.     

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。     

Application of the ASSES scale for the assessment of patient state severity and outcome prediction of acute pancreatitis

There was estimated the severity state in 129 patients, suffering an acute pancreatitis, using the ASSES, SAPS, APACHE II and V. S. Savelyev's scales. Trustworthy differences of their values were established in survivors and the dead patients immediately after admitting to the hospital, before the operation, in 1-2 and 3-4 days after the operation. The best accuracy in predicting of outcome after the patient admittance to the hospital and in early postoperative period was noted while using the ASSES scale. The sum more than 13 points after admittance to the hospital and before the operation, as well as more than 16 points on the first-second and the third-fourth postoperative days, according to the ASSES scale, witnesses unfavorable prognosis of the disease.     

Clinical value of severity markers in acute pancreatitis.

Acute pancreatitis is a common digestive disease of which the severity may vary from mild, edematous to severe, necrotizing disease. An improved outcome in the severe form of the disease is based on early identification of disease severity and subsequent focused management of these high-risk patients. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe acute pancreatitis is not accurate. Prospective systems using clinical criteria have been used to determine severity in patients with acute pancreatitis, such as the Ranson's prognostic signs, Glasgow score, and the acute physiology and chronic health evaluation II score (APACHE II). Their application in clinical practise has been limited by the time delay of at least 48 h to judge all parameters in the former two and by being cumbersome and time-consuming in the latter. Contrast-enhanced computed tomography is presently the most accurate non-invasive single method to evaluate the severity of acute pancreatitis. It cannot, however, be performed to all patients with acute pancreatitis. Therefore, considerable interest has grown in the development of reliable biochemical markers that reflect the severity of acute pancreatitis. In this article we critically appraise current and new severity markers of acute pancreatitis in their ability to distinguish between mild and severe disease and their clinical utility.     

Contrast-enhanced abdominal computed tomography scanning and prediction of severity of acute pancreatitis: a prospective study

One hundred and fifty-two patients were admitted to a single hospital with a diagnosis of acute pancreatitis during a 31-month period. Of these, 126 patients had contrast-enhanced abdominal computed tomography (CT) scans within 72 h of admission; 92 of these attacks were clinically mild, 34 were clinically severe. A single consultant radiologist reported the scans 'blind' and noted whether pancreatic enhancement was normal, increased or decreased, and whether there was loss of peripancreatic tissue planes. The maximum anteroposterior measurement of the pancreatic head and body were multiplied together to produce a 'pancreatic size index' (cm2). Significantly more patients with severe attacks had decreased pancreatic enhancement (79 versus 58 per cent, P = 0.01) and loss of peripancreatic tissue planes (82 versus 54 per cent, P = 0.006). The median (range) pancreatic size index for clinically severe attacks was 12.8 cm2 (3.0-52.5), and for mild attacks was 6.0 cm2 (1.1-23.4), P less than 0.0001. Modified Glasgow criteria had a sensitivity of 85 per cent and specificity of 79 per cent for clinically severe attacks. A pancreatic size index of greater than or equal to 10 cm2 had a sensitivity of 71 per cent and specificity of 77 per cent for clinically severe attacks. In conclusion, although there were highly significant differences between the clinically severe and mild groups with respect to pancreatic enhancement, peripancreatic tissue planes and pancreatic size indices, these CT criteria did not improve on modified Glasgow criteria for prediction of disease severity.     

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.     

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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。     

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.     

Comparative analysis of the scores of severity of acute pancreatitis

Based on an analysis of case histories of 45 patients with destructive pancreatitis and coexisting peritonitis the authors have proposed a score assessment of the disease severity. It is based on accounting the morphological alterations in the pancreas and retroperitoneal fat, statistical data from case histories of the patients. This method of assessing the severity of acute pancreatitis is good for specification of the management of the patient in the hospital and for a retrospective analysis of the case history.