Acute pancreatitis natural history, complications and prognosis
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Pancreatitis can be mild or severe, and the natural history will depend on the severity of the condition, and the timeliness of intervention. Acute pancreatitis can result in complications such as hemorrhagic pancreatitis, multisystem organ failure, infection, SIRS, ARDS, hyperglycemia, hypocalcemia, shock, hemorrhage, thrombosis, common bile duct obstruction, and the development of chronic pancreatitis. In predicting the prognosis, there are several scoring indices that have been used as predictors of survival.  These scoring systems combine radiographic, laboratory, and clinical findings in an attempt to predict prognosis. Some of these include the Ranson criteria, APACHE II, APACHE-O (APACHE with Obesity), Glasgow score, HAPS, PANC-3, JSS, POP, and BISAP. These scoring systems are extremely cumbersome to use and are associated with a high false positive rate. While imaging studies are vital component of patient work up and follow up, they often lag the clinical presentation. None of the scoring systems are able to replace an experienced, attentive physician's ongoing clinical assessment of the patient.
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.
There are several ways to help distinguish between these two forms. One is the above mentioned Ranson Score.
Determinants of the natural course of acute pancreatitis are:
Early in the course of acute pancreatitis, multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury, the so-called systemic inflammatory response syndrome (SIRS). SIRS is the cause of bacterial (gram negative) translocation from the patients colon. Local and systemic septic complications, when they occur, typically do so at least a week after presentation.
Complications can be systemic or locoregional.
- Systemic complications include:
- ARDS (Acute respiratory distress syndrome)
- Pleural effusion
- Mediastinal fluid
- Nonspecific ST-T changes in electrocardiogram simulating myocardial infarction
- Pericardial effusion
- Peptic ulcer disease
- Erosive gastritis
- Hemorrhagic pancreatic necrosis with erosion into major blood vessels
- Oliguria (<300 mL/d)
- Renal artery and/or renal vein thrombosis
- Acute tubular necrosis
- Multiple organ dysfunction syndrome
- Exacerbation of COPD
- Exacerbation of CHF
- Exacerbation of Hepatitis
- Hypocalcemia (from fat saponification)
- Sudden blindness (Purtscher’s retinopathy)
- Fat emboli
- Insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
- Locoregional complications include:
- Pancreatic pseudocyst or walled off pancreatic necrosis
- Phlegmon / abscess formation,
- Splenic artery pseudoaneurysm
- 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
- Pancreatic enteric fistula
- Bowel infarction
- Obstructive jaundice
- Disruption of main pancreatic duct or secondary branches
- Pancreatic ascites
According to the American college of gastroenterology, following are the guidelines for initial assessment and risk stratification for acute pancreatitis:
|Intrinsic patient related risk factors|
|Patient characteristics||Age >55 years|
|Altered mental status|
|The systemic inflammatory response syndrome (SIRS)
Presence of >2 of the following criteria
|Pulse >90 beats/min|
or PaCO2 >32mmHg
|Temperature >38°C or <36°C|
|WBC count >12,000 or <4000 cells/mm3
or >10% immature neutrophils (bands)
|Laboratory findings||BUN >20 mg/dl|
|Radiology findings||Pleural effusions|
|Multiple or extensive extrapancreatic collections|
In predicting the prognosis, there are several scoring indices that have been used as predictors of survival.  These scoring systems combine radiographic, laboratory, and clinical findings in an attempt to predict prognosis. Some of these include the Ranson criteria, APACHE II, APACHE-O (APACHE with Obesity), Glasgow score, HAPS, PANC-3, JSS, POP, and BISAP. These scoring systems are extremely cumbersome to use and are associated with a high false positive rate. While imaging studies are vital component of patient work up and follow up, they often lag the clinical presentation. 
None of the scoring systems are able to replace an experienced, attentive clinicians assessment of the patient. In general, prognostic factors may be classified as follows:
|Poor Clinical Prognostic Factors||Comment|
|Type II Diabetes||2-3 fold risk of mortality|
|Persistent Organ System Failure (>48 hrs)||Prime determinant of poor outcome|
|Hospital Acquired Infection||9-10 fold risk of mortality|
|Advanced Age||>60 years|
|SIRS persisting >48 hours||Temp:>38C or <36C; Pulse>90/min; RR:>20/min; WBC:<4000 or >12000.|
|Poor Biomarker Prognostic Factors||Comment|
|Elevated CRP, IL-6, IL-8, or IL-10|
|BUN, Cr, and Hematocrit||When they do not return to normal with fluid resuscitation.|
Cross-sectional imaging should be utilized in assessing the progression of the complications, though imaging findings may lag the clinical presentation:
|Encapsulated with a wall|
(within 4 weeks)
|Necrosis Present||No||Acute peripancreatic fluid collection||Pancreatic pseudocyst|
|Yes||Acute necrotic collection||Walled off pancreatic necrosis|
Severity scoring systems can be cumbersome to utilize and no single system has been established as a gold standard. Nevertheless, clinicians may find utility in using the following scoring systems, in conjunction with serial CT scans, and regular and thorough clinical assessments of the patient.
- Hemorrhagic peritoneal fluid
- 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)>
The death rate is high with:
The APACHE score has been combined with a higher weight given to Obesity, in what is now defined as the APACHE-O score.
The Glasgow criteria is valid for both gallstone and alcohol induced pancreatitis. If a patient scores 3 or more it indicates severe pancreatitis and the patient should be transferred to ITU.
- PaO2 <8kPa
- Age >55 years old
- Neutrophilia - WCC >15x10(9)/L
- Serum calcium <2mmol/L
- Renal function, Urea >16mmol/L
- LDH >600iu/L; AST >200iu/L
- Albumin <32g/L (serum)
- Blood glucose >10mmol/L
Bedside index for severity in acute pancreatitis (BISAP), has been proposed as an accurate method for early identification of patients at risk for in-hospital mortality. Criteria used in this score are as follows:
- Blood urea nitrogen - >25
- Impaired mental status
- Systemic inflammatory response syndrome(SIRS) - (>/= 2 criteria)
- Age - >60 yrs
- Pleural effusion on CT
|BISAP Score||Observed Mortality|
The advantages of BISAP score over other scoring systems are:
- Easy to obtain
- Prognostic efficacy similar to other scoring systems
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