Pancreatitis natural history, complications and prognosis
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Pancreatitis Main Page |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Complications of pancreatitis should be suspected when there is persistence/recurrence of abdominal pain, secondary increases in pancreatic enzyme, increasing organ dysfunction, or the development of signs of sepsis.[1] There are several scoring systems used to help predict the severity of an attack of pancreatitis. The Apache II has the advantage being available at the time of admission as opposed to 48 hours later for the Glasgow criteria and Ranson criteria. However, the Glasgow criteria and Ranson criteria are easier to use.
Complications
Local Complications
▸ Should be suspected when there is persistence/recurrence of abdominal pain, secondary increases in pancreatic enzyme, increasing organ dysfunction, or the development of signs of sepsis.[1]
Local complications can be divided according to time frame.[1]
| Time frame | Complication |
|---|---|
| Less than 4 weeks | 1. Acute peripancreatic fluid collections 2. Acute necrotic collections |
| More than 4 weeks | 1.Pancreatic pseudocyst 2. Walled-off necrosis (WON) |
- Acute Peripancreatic Fluid Collection (APFC)
- ▸ Peripancreatic fluid associated with interstitial edematous pancreatitis with no associated peripancreatic necrosis. This term applies only to areas of peripancreatic fluid seen within the first 4 weeks after onset of interstitial edematous pancreatitis and without the features of a pseudocyst.
- CECT criteria
- ▸ Occurs in the setting of interstitial edematous pancreatitis.
- ▸ Homogeneous collection with fluid density.
- ▸ Confined by normal peripancreatic fascial planes.
- ▸ No definable wall encapsulating the collection.
- ▸ Adjacent to pancreas (no intrapancreatic extension).
- Pancreatic Pseudocyst
- ▸ An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no necrosis. This entity usually occurs more than 4 weeks after onset of interstitial edematous pancreatitis to mature.
- CECT criteria
- ▸ Well circumscribed, usually round or oval.
- ▸ Homogeneous fluid density.
- ▸ No non-liquid component.
- ▸ Well defined wall; that is, completely encapsulated.
- ▸ Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis.
- Acute necrotic collection (ANC)
- ▸ A collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis; the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues.
- CECT criteria
- ▸ Occurs only in the setting of acute necrotising pancreatitis.
- ▸ Heterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course).
- ▸ No definable wall encapsulating the collection.
- ▸ Location—intrapancreatic and/or extrapancreatic.
- Walled-off necrosis (WON)
- ▸ A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well defined inflammatory wall. WON usually occurs >4 weeks after onset of necrotising pancreatitis.
- CECT criteria
- ▸ Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous).
- ▸ Well defined wall, that is, completely encapsulated.
- ▸ Location—intrapancreatic and/or extrapancreatic.
- ▸ Maturation usually requires 4 weeks after onset of acute necrotizing pancreatitis
- Infected necrosis
- ▸ 33% of pancreatitis patients with acute pancreatic necrosis develop infected necrosis.[2]
- ▸ Gram negative organisms from the small bowel contaminate and cause infection which usually presents late in the course.[3][4]
- ▸ A high degree of suscipicion should be kept when patient don't improve even after aggressive treatment.
- ▸ Failure to respond warrants an investigation which are CT scan, culture and gram staining.[5][6]
- ▸ Empirical therapy specially with high penetration in the pancreas like carbapenems should be prescribed.[7][3]
- ▸ Debridement of the necrosis should be considered after initiating and localizing infection.[7][3]
- ▸ Witholding of the surgery can be done and the necrosis can be managed conservatively if needed.[8][9][10][11]
Systemic Complications
▸ Defined as exacerbation of pre-existing co-morbidity, such as coronary artery disease or chronic lung disease, precipitated by the acute pancreatitis.
Organ Failure
- Modified Marshall Scoring System
| Organ System | 0 | 1 | 2 | 3 | 4 |
| Respiratory PaO2/FiO2 |
>400 | 301-400 | 201-300 | 101-200 | ≤101 |
| Renal‡ Creatinine (μmol/l) Creatinine (mg/dl) |
≤134 <1.4 |
134-169 1.4-1.8 |
170-310 1.9-3.6 |
311-439 3.6-4.9 |
>439 >4.9 |
| Cardiovascular Systolic Blood Pressure (mmHg) |
>90 | <90, fluid responsive | <90, not fluid responsive | <90, pH <7.3 | <90, pH <7.2 |
† A score of 2 or more in any system defines the presence of organ failure.
‡ A score for patients with pre-existing chronic renal failure depends on the extent of further deterioration of baseline renal function. No formal correction exists for a baseline creatinine ≥134 μmol/l or ≥1.4 mg/dl.
▸ For non-ventilated patients, the FiO2 can be estimated from below:
| Supplemental oxygen (l/min) | FiO2 (%) |
| Room air | 21 |
| 2 | 25 |
| 4 | 30 |
| 6–8 | 40 |
| 9–10 | 50 |
- Transient organ failure = organ failure resolves within 48 h.
- Persistent organ failure = organ failure persists for >48 h.[12][13][14]
Prognosis
There are several scoring systems used to help predict the severity of an attack of pancreatitis. The Apache II has the advantage being available at the time of admission as opposed to 48 hours later for the Glasgow criteria and Ranson criteria. However, the Glasgow criteria and Ranson criteria are easier to use.
APACHE II
Ranson Criteria
- At admission:
- Age in years >55years
- White blood cell count > 16000/mcL
- Blood glucose > 11 mmol/L (>200 mg/dL)
- Serum AST > 250 IU/L
- Serum LDH > 350 IU/L
- After 48 hours:
- Hematocrit fall > 10%
- Increase in BUN by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
- Hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
- Hypoxemia (PO2 < 60 mmHg)
- Base deficit > 4Meq/L
- Estimated fluid sequestration > 6L
The criteria for point assignment is that a certain breakpoint be met at anytime during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both biliary and alcoholic pancreatitis.
Interpretation
- If the score >=3, severe pancreatitis likely.
- If the score < 3, severe pancreatitis is unlikely
Or
- Score 0 to 2 : 2% mortality
- Score 3 to 4 : 15% mortality
- Score 5 to 6 : 40% mortality
- Score 7 to 8 : 100% mortality
Glasgow Criteria
Glasgow's criteria[15]: The original system used 9 data elements. This was subsequently modified to 8 data elements, with removal of assessment for transaminase levels (either AST (SGOT) or ALT (SGPT) greater than 100 U/L).
- On Admission
- Within 48 hours
References
- ↑ 1.0 1.1 1.2 Banks, PA.; Bollen, TL.; Dervenis, C.; Gooszen, HG.; Johnson, CD.; Sarr, MG.; Tsiotos, GG.; Vege, SS.; Acosta, JM. (2013). "Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus". Gut. 62 (1): 102–11. doi:10.1136/gutjnl-2012-302779. PMID 23100216. Unknown parameter
|month=ignored (help) - ↑ Banks, PA.; Freeman, ML. (2006). "Practice guidelines in acute pancreatitis". Am J Gastroenterol. 101 (10): 2379–400. doi:10.1111/j.1572-0241.2006.00856.x. PMID 17032204. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 3.2 Beger, HG.; Bittner, R.; Block, S.; Büchler, M. (1986). "Bacterial contamination of pancreatic necrosis. A prospective clinical study". Gastroenterology. 91 (2): 433–8. PMID 3522342. Unknown parameter
|month=ignored (help) - ↑ Bradley, EL.; Allen, K. (1991). "A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis". Am J Surg. 161 (1): 19–24, discussion 24-5. PMID 1987854. Unknown parameter
|month=ignored (help) - ↑ Walser, EM.; Nealon, WH.; Marroquin, S.; Raza, S.; Hernandez, JA.; Vasek, J. "Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration". Cardiovasc Intervent Radiol. 29 (1): 102–7. doi:10.1007/s00270-004-0220-4. PMID 16283578.
- ↑ Mortelé, KJ.; Girshman, J.; Szejnfeld, D.; Ashley, SW.; Erturk, SM.; Banks, PA.; Silverman, SG. (2009). "CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis". AJR Am J Roentgenol. 192 (1): 110–6. doi:10.2214/AJR.08.1116. PMID 19098188. Unknown parameter
|month=ignored (help) - ↑ 7.0 7.1 Yasuda, T.; Ueda, T.; Takeyama, Y.; Shinzeki, M.; Sawa, H.; Nakajima, T.; Matsumoto, I.; Fujita, T.; Sakai, T. (2007). "Treatment strategy against infection: clinical outcome of continuous regional arterial infusion, enteral nutrition, and surgery in severe acute pancreatitis". J Gastroenterol. 42 (8): 681–9. doi:10.1007/s00535-007-2081-5. PMID 17701132. Unknown parameter
|month=ignored (help) - ↑ Baron, TH.; Morgan, DE. (1999). "Endoscopic transgastric irrigation tube placement via PEG for debridement of organized pancreatic necrosis". Gastrointest Endosc. 50 (4): 574–7. PMID 10502187. Unknown parameter
|month=ignored (help) - ↑ Clancy, TE.; Ashley, SW. (2002). "Current management of necrotizing pancreatitis". Adv Surg. 36: 103–21. PMID 12465548.
- ↑ Jacobson, BC.; Baron, TH.; Adler, DG.; Davila, RE.; Egan, J.; Hirota, WK.; Leighton, JA.; Qureshi, W.; Rajan, E. (2005). "ASGE guideline: The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas". Gastrointest Endosc. 61 (3): 363–70. PMID 15758904. Unknown parameter
|month=ignored (help) - ↑ Seewald, S.; Groth, S.; Omar, S.; Imazu, H.; Seitz, U.; de Weerth, A.; Soetikno, R.; Zhong, Y.; Sriram, PV. (2005). "Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos)". Gastrointest Endosc. 62 (1): 92–100. PMID 15990825. Unknown parameter
|month=ignored (help) - ↑ Johnson, CD.; Abu-Hilal, M. (2004). "Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis". Gut. 53 (9): 1340–4. doi:10.1136/gut.2004.039883. PMID 15306596. Unknown parameter
|month=ignored (help) - ↑ Mofidi, R.; Duff, MD.; Wigmore, SJ.; Madhavan, KK.; Garden, OJ.; Parks, RW. (2006). "Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis". Br J Surg. 93 (6): 738–44. doi:10.1002/bjs.5290. PMID 16671062. Unknown parameter
|month=ignored (help) - ↑ Lytras, D.; Manes, K.; Triantopoulou, C.; Paraskeva, C.; Delis, S.; Avgerinos, C.; Dervenis, C. (2008). "Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis?". Pancreas. 36 (3): 249–54. doi:10.1097/MPA.0b013e31815acb2c. PMID 18362837. Unknown parameter
|month=ignored (help) - ↑ Corfield AP, Cooper MJ, Williamson RC; et al. (1985). "Prediction of severity in acute pancreatitis: prospective comparison of three prognostic indices". Lancet. 2 (8452): 403–7. PMID 2863441.