Acute pancreatitis natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
Natural History
Acute pancreatitis can be further divided in mild and severe pancreatitis. Mostly the Atlanta classification (1992) is used. In severe pancreatitis serious amount of necrosis determine the further clinical outcome. About 20% of the acute pancreatitis are severe with a mortality of about 20%. This is an important classification as severe pancreatitis will need intensive care therapy whereas mild pancreatitis can be treated on the common ward.
Necrosis will be followed by a systemic inflammation response syndrome (SIRS) and will determine the immediate clinical course. The further clinical course is then determined by bacterial infection. SIRS is the cause of bacterial (Gram negative) translocation from the patients colon.
There are several ways to help distinguish between these two forms. One is the above mentioned Ranson Score.
Complications
Complications can be systemic or locoregional.
- Systemic complications include ARDS, multiple organ dysfunction syndrome, DIC, hypocalcemia (from fat saponification), hyperglycemia and insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
- Locoregional complications include pancreatic pseudocyst and phlegmon / abscess formation, splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, thrombosis of the splenic vein, superior mesenteric vein and portal veins (in descending order of frequency), duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis
Prognosis
In predicting the prognosis, there are several scoring indices that have been used as predictors of survival. Two such scoring systems are the Ranson and APACHE II (Acute Physiology, Age and Chronic Health Evaluation) indices. Most[1] [2], but not all [3] studies report that the Apache score may be more accurate. In the negative study of the Apache II [3], the Apache II 24 hr score was used rather than the 48 hour score. In addition, all patients in the study received at ultrasound twice which may have influenced allocation of co-interventions. Regardless, only the Apache II can be fully calculated upon admission. As the Apache II is more cumbersome to calculate, presumably patients whose only laboratory abnormality is an elevated lipase or amylase do not need prognostication with the Apache II; however, this approach is not studied. The Apache II score can be calculated at www.sfar.org.
Practice guidelines state:
- 2006: "The two tests that are most helpful at admission in distinguishing mild from severe acute pancreatitis are APACHE-II score and serum hematocrit. It is recommended that APACHE-II scores be generated during the first 3 days of hospitalization and thereafter as needed to help in this distinction. It is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscitation."[4]
- 2005: "Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score" [5]
Ranson
APACHE
"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality [4] Online calculator
- Hemorrhagic peritoneal fluid
- Obesity
- Indicators of organ failure
- Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min
- PO2 <60 mmHg
- Oliguria (<50 mL/h) or increasing BUN and creatinine
- Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>
References
- ↑ Larvin M, McMahon M (1989). "APACHE-II score for assessment and monitoring of acute pancreatitis". Lancet. 2 (8656): 201–5. PMID 2568529.
- ↑ Yeung Y, Lam B, Yip A (2006). [www.hbpdint.com/text.asp?id=837 "APACHE system is better than Ranson system in the prediction of severity of acute pancreatitis"] Check
|url=value (help). Hepatobiliary Pancreat Dis Int. 5 (2): 294–9. PMID 16698595. - ↑ 3.0 3.1 Chatzicostas C, Roussomoustakaki M, Vlachonikolis I, Notas G, Mouzas I, Samonakis D, Kouroumalis E (2002). "Comparison of Ranson, APACHE II and APACHE III scoring systems in acute pancreatitis". Pancreas. 25 (4): 331–5. PMID 12409825 (comment=this study used a Apache cutoff of >=10).
- ↑ 4.0 4.1 Banks P, Freeman M (2006). "Practice guidelines in acute pancreatitis". Am J Gastroenterol. 101 (10): 2379–400. doi:10.1111/j.1572-0241.2006.00856.x. PMID 17032204.
- ↑ Anonymous (2005). "UK Working Party on Acute Pancreatitis: UK guidelines for the management of acute pancreatitis". Gut. 54 Suppl 3: iii1–9. doi:10.1136/gut.2004.057026 url=http://gut.bmj.com/cgi/content/full/54/suppl_3/iii1 Check
|doi=value (help). PMID 15831893.