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]; Tarek Nafee, M.D. [3]
Overview
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. [1] 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 a vital component of patient work-up and follow-up, they often lack the clinical presentation. None of the scoring systems are able to replace an experienced, attentive physician's ongoing clinical assessment of the patient.
Natural History
Acute pancreatitis can be further divided in mild and severe pancreatitis. Mostly the Atlanta classification (1992) is used. In severe pancreatitis a 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.[2][3]
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:
- Multisystem organ failure,
- Pancreatic parenchymal necrosis,
- Extrapancreatic retroperitoneal fatty tissue necrosis,
- Biologically active compounds in pancreatic ascites,
- Infection after necrosis,
- Clinical factors, including age and obesity.
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
Complications can be systemic or locoregional.
Systemic complications:
- Systemic complications include:
- ARDS (Acute respiratory distress syndrome)
- Pleural effusion
- Atelectasis
- Mediastinal fluid
- Pneumonitis
- Hypotension
- Hypovolemia
- 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)
- Azotemia
- Renal artery and/or renal vein thrombosis
- Acute tubular necrosis
- Multiple organ dysfunction syndrome
- DIC
- Exacerbation of COPD
- Exacerbation of CHF
- Exacerbation of Hepatitis
- Hypocalcemia (from fat saponification)
- Hyperglycemia
- Hypertriglyceridemia
- Sudden blindness (Purtscher’s retinopathy)
- Psychosis
- Fat emboli
- Insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
- Shock
Local complications:
- 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
Prognosis
According to the American College of Gastroenterology, the following are the guidelines for initial assessment and risk stratification for acute pancreatitis:[4][5][6][7][8][9][10][11][12][13][14][15][16]
| Intrinsic patient related risk factors | |
|---|---|
| Patient characteristics | Age >55 years |
| Obesity (BMI>30kg/m2) | |
| Altered mental status | |
| Comorbid disease | |
| The systemic inflammatory response syndrome (SIRS)
Presence of >2 of the following criteria |
Pulse >90 beats/min |
| Respirations >20/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 |
| Rising BUN | |
| HCT >44% | |
| Rising HCT | |
| Elevated creatinine | |
| Radiology findings | Pleural effusions |
| Pulmonary infiltrates | |
| Multiple or extensive extrapancreatic collections |
In predicting the prognosis, there are several scoring indices that have been used as predictors of survival. [1] 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 lack the clinical presentation. [17]
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:[5][18][1][19][20][21][4][22][17]
| Poor Clinical Prognostic Factors | Comment |
|---|---|
| Type II Diabetes | 2-3 fold risk of mortality |
| Morbid Obesity | BMI>30 |
| 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 lack the clinical presentation:
| Encapsulated with a wall | |||
|---|---|---|---|
| No
(within 4 weeks) |
Yes
(>4 weeks) | ||
| Necrosis Present | No | Acute peripancreatic fluid collection | Pancreatic pseudocyst |
| Yes | Acute necrotic collection | Walled off pancreatic necrosis | |
Scoring Systems
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.[5][18][1][19][20][21][4][22][17]
Ranson
APACHE
"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality [23] 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)>
The death rate is high with:
- Hemorrhagic pancreatitis
- Liver, heart, or kidney impairment
- Necrotizing pancreatitis
The APACHE score has been combined with a higher weight given to Obesity, in what is now defined as the APACHE-O score.
Glasgow Criteria
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
BISAP Score[24]
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
Scoring system:
| BISAP Score | Observed Mortality |
|---|---|
| 0 | 0.1% |
| 1 | 0.4% |
| 2 | 1.6% |
| 3 | 3.6% |
| 4 | 7.4% |
| 5 | 9.5% |
The advantages of BISAP score over other scoring systems are:
- Accuracy
- Simple
- Easy to obtain
- Prognostic efficacy similar to other scoring systems
References
- ↑ 1.0 1.1 1.2 1.3 Dellinger EP, Forsmark CE, Layer P, Lévy P, Maraví-Poma E, Petrov MS; et al. (2012). "Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation". Ann Surg. 256 (6): 875–80. doi:10.1097/SLA.0b013e318256f778. PMID 22735715.
- ↑ Yadav D, O'Connell M, Papachristou GI (2012). "Natural history following the first attack of acute pancreatitis". Am. J. Gastroenterol. 107 (7): 1096–103. doi:10.1038/ajg.2012.126. PMID 22613906.
- ↑ Beger HG, Rau B, Isenmann R (2003). "Natural history of necrotizing pancreatitis". Pancreatology. 3 (2): 93–101. doi:10.1159/000070076. PMID 12774801.
- ↑ 4.0 4.1 4.2 Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955.
- ↑ 5.0 5.1 5.2 Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, Singh VK, Slivka A, Whitcomb DC, Yadav D, Banks PA, Papachristou GI (2012). "Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis". Gastroenterology. 142 (7): 1476–82, quiz e15–6. doi:10.1053/j.gastro.2012.03.005. PMID 22425589.
- ↑ Brown A, Orav J, Banks PA (2000). "Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis". Pancreas. 20 (4): 367–72. PMID 10824690.
- ↑ Tran DD, Cuesta MA (1992). "Evaluation of severity in patients with acute pancreatitis". Am. J. Gastroenterol. 87 (5): 604–8. PMID 1595648.
- ↑ 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.
- ↑ Buter A, Imrie CW, Carter CR, Evans S, McKay CJ (2002). "Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis". Br J Surg. 89 (3): 298–302. doi:10.1046/j.0007-1323.2001.02025.x. PMID 11872053.
- ↑ Papachristou GI, Muddana V, Yadav D, Whitcomb DC (2010). "Increased serum creatinine is associated with pancreatic necrosis in acute pancreatitis". Am. J. Gastroenterol. 105 (6): 1451–2. doi:10.1038/ajg.2010.92. PMID 20523325.
- ↑ Heller SJ, Noordhoek E, Tenner SM, Ramagopal V, Abramowitz M, Hughes M, Banks PA (1997). "Pleural effusion as a predictor of severity in acute pancreatitis". Pancreas. 15 (3): 222–5. PMID 9336784.
- ↑ Funnell IC, Bornman PC, Weakley SP, Terblanche J, Marks IN (1993). "Obesity: an important prognostic factor in acute pancreatitis". Br J Surg. 80 (4): 484–6. PMID 8495317.
- ↑ Mann DV, Hershman MJ, Hittinger R, Glazer G (1994). "Multicentre audit of death from acute pancreatitis". Br J Surg. 81 (6): 890–3. PMID 8044613.
- ↑ Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA (2000). "Does mortality occur early or late in acute pancreatitis?". Int. J. Pancreatol. 28 (2): 91–5. doi:10.1385/IJGC:28:2:091. PMID 11128978.
- ↑ 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. PMC 1774183. PMID 15306596.
- ↑ 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.
- ↑ 17.0 17.1 17.2 Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ 18.0 18.1 Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG; et al. (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.
- ↑ 19.0 19.1 Hong S, Qiwen B, Ying J, Wei A, Chaoyang T (2011). "Body mass index and the risk and prognosis of acute pancreatitis: a meta-analysis". Eur J Gastroenterol Hepatol. 23 (12): 1136–43. doi:10.1097/MEG.0b013e32834b0e0e. PMID 21904207.
- ↑ 20.0 20.1 Wu BU, Johannes RS, Kurtz S, Banks PA (2008). "The impact of hospital-acquired infection on outcome in acute pancreatitis". Gastroenterology. 135 (3): 816–20. doi:10.1053/j.gastro.2008.05.053. PMC 2570951. PMID 18616944.
- ↑ 21.0 21.1 Working Group IAP/APA Acute Pancreatitis Guidelines (2013). "IAP/APA evidence-based guidelines for the management of acute pancreatitis". Pancreatology. 13 (4 Suppl 2): e1–15. doi:10.1016/j.pan.2013.07.063. PMID 24054878.
- ↑ 22.0 22.1 Yadav D, Lowenfels AB (2013). "The epidemiology of pancreatitis and pancreatic cancer". Gastroenterology. 144 (6): 1252–61. doi:10.1053/j.gastro.2013.01.068. PMC 3662544. PMID 23622135.
- ↑ 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.
- ↑ Papachristou GI, Muddana V, Yadav D; et al. (2010). "Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis". Am. J. Gastroenterol. 105 (2): 435–41, quiz 442. doi:10.1038/ajg.2009.622. PMID 19861954. Unknown parameter
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