Atlanta Classification System Research Articles

Cytokine Dynamics in Acute Pancreatitis: The Quest for Biomarkers from Acute Disease to Disease Resolution.

Background: Acute pancreatitis (AP) is an inflammatory disease of the pancreas with incompletely known pathogenic mechanisms. This study aimed to explore the temporal changes in serum cytokines in patients with AP and to assess the association of these changes with disease severity. Methods: Fifty patients hospitalized with AP were enrolled, and their serum cytokine levels were analyzed at four different time points. A healthy control (HC) group of 30 outpatients was included. Results: AP patients showed increased levels of interleukin (IL)-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF)-alpha, and monocyte chemoattractant protein (MCP)-1 at admission when compared with HC. IL-6, VEGF, and EGF remained elevated 1 month after hospitalization and 6 months after discharge. Conclusions the Bedside Index of Severity in Acute Pancreatitis (BISAP) and severity classification of the revised Atlanta classification system, IL-6 and VEGF, determined 48 h after hospitalization, were the two cytokines consistently elevated in the most severe patients. Increased levels of IL-4, IL-6, IL-10, and TNF-alpha at admission and MCP-1 48 h after admission are also related to the length of hospital stay. Conclusions: Our study highlights the role cytokines play in the pathogenesis of AP and can be useful in the development of future drug trials for AP.

Circulating Blood B and T Lymphocytes and Severity of Acute Pancreatitis: A Systematic Review Protocol.

Acute pancreatitis is an acute inflammatory process of the pancreas with a high prevalence rate and varying degrees of severity that can be potentially life threatening. Much is still unknown about which mechanisms determine the course and severity of acute pancreatitis. The primary objective of this review is to identify the potential association between circulating B and T lymphocytes and the severity of acute pancreatitis. Subgroup analyses will be done according to the severity classification of the Revised Atlanta Classification System as well as according to the distinction between B lymphocytes and T lymphocytes and the severity of acute pancreatitis. A systematic search will be performed in Medline, Web of Science, EMBASE, Cochrane Central Register of Controlled trials and ClinicalTrials.gov. Three authors will independently do the selection process as well as data extraction that will be recorded into a flow diagram following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The pathophysiology of acute pancreatitis is still not fully understood and its evolution is sometimes unpredictable. In this context, through this systematic review, the research team intends to determine what has been described about the role of serum lymphocytes in determining the severity of acute pancreatitis, by identifying a potential indicator of the severity of this acute disease.

Imaging Features of Acute Pancreatitis and the Revised Atlanta Classification System

Acute pancreatitis is a major cause of hospital admissions in the United States, with the two primary causes being gallstones and alcohol.1 The Atlanta classification system is an international classification on the severity of acute pancreatitis. In 2012, deficiencies and outdated nomenclature were removed to make a revised system that take into account advancements in research and clinical management. The revised Atlanta classification system (RACS) in 2012 standardized the nomenclature for acute pancreatitis and local complications to facilitate effective communication between clinicians and radiologists alike. Older terms such as pancreatic abscess, phlegmon, acute pseudocyst, and fluid collection are no longer used, as they are vague and can be misleading.

Imaging Features of Acute Pancreatitis and the Revised Atlanta Classification System

Contemporary Diagnostic Radiology 46(2):p 8, January 15, 2023. | DOI: 10.1097/01.CDR.0000905608.54137.e2

Nomenclature of Pancreatic Fluid Collections following Acute Pancreatitis: Need to Further Revise the Atlanta Classification System!

AbstractA better understanding of the disease pathophysiology, improved imaging modalities, and the development of minimally invasive interventions led to the revision of the Atlanta classification and new terminologies for the pancreatic fluid collections (PFCs) occurring in acute pancreatitis. Peripancreatic necrosis (PPN) or extra-pancreatic necrosis (EPN) has been reported as a distinct morphological entity with a better outcome than combined pancreatic and peripancreatic necrosis as well as pancreatic parenchymal necrosis alone and slightly worse than acute interstitial pancreatitis. In this news and views, we discuss a study that compared the morphological features and outcomes of endoscopic drainage of walled off necrotic collections developing after EPN alone with those developing after PN with or without EPN.

IL-10-1082G>A polymorphism, use of opioids and age affect the course of acute pancreatitis.

We aimed to determine the association of two of the most important functional polymorphisms of IL-8 and IL-10 with the clinical course and outcome of acute pancreatitis. Ninety-three patients with acute pancreatitis were genotyped for IL-8-251T>A and IL-10-1082G>A using PCR-RFLP. The severity of the disease was determined based on the Atlanta Classification system. In patients treated with opioids, the odds for severe form of acute pancreatitis, its complications, and death were increased. Advanced age was associated with higher odds of organ/multiple organ failure and other systemic complications. Multivariate logistic regression analyses confirmed the observed effect of age and use of opioids, and revealed higher odds for the development of severe form of acute pancreatitis [P = 0.017, odds ratio (OR): 4.324, 95% confidence interval (CI): 1.305-14.323], its complications in general (P = 0.011, OR: 4.936, 95% CI: 1.442-16.897), pancreatic necrosis (P = 0.032, OR: 3.922, 95% CI: 1.122-13.707) and systemic inflammatory response syndrome (P = 0.037, OR: 3.838, 95% CI: 1.085-13.583) in the absence of IL-10-1082G>A variant allele. The effect of IL-8 -251T>A on acute pancreatitis severity or mortality was not detected. Our study suggests the IL-10 -1082A allele as a protective factor in acute pancreatitis. Opioid analgesics treatment in acute pancreatitis is associated with severity, complications and mortality, while advanced age increases the risk of systemic complications.

Acute pancreatitis: an update on the revised Atlanta classification.

Acute pancreatitis (AP) is the most common gastrointestinal disease resulting in hospitalization in the United States with reports of over 270,000 hospitalizations and costs up to 2.6 billion dollars per year. AP is highly variable in disease course and outcome. Established in 1992, the original Atlanta classification system aimed to categorize the wide spectrum of AP by creating consensus-based terminology for AP types, severity, and complications. Though the original system standardized terminology, certain terms and definitions (i.e. pancreatic abscess) were unclear and often misused. The 2012 revised Atlanta classification (RAC) system updated terms, clarified definitions, and incorporated the medical community's improved understanding of the physiology of AP. The resulting RAC effectively defined the morphologic types of pancreatitis, provided a more standardized system for disease severity grading, further classified the local retroperitoneal complications, and established objective measures to describe this highly variable but common disease. This review provides an update on the recent literature evaluating the RAC, discusses both the strengths and shortcomings of the RAC system (including problematic interobserver agreement), and considers improvements for future classification systems.

CFTR IVS8 Poly-T Variation Affects Severity of Acute Pancreatitis in Women

BackgroundCystic fibrosis transmembrane conductance regulator (CFTR) is important for normal pancreatic function. Its coding gene is polymorphic, and the variations have been associated with the increased risk for acute pancreatitis. However, their impact on the disease severity is still unknown. Therefore, the aim of our study was to determine the functional importance of common cystic fibrosis transmembrane conductance regulator variations IVS8-poly T, R117H, and M470V for the severity of acute pancreatitis. MethodThe study involved 98 acute pancreatitis patients. The severity of the disease was determined based on the Atlanta Classification system. IVS8-poly T, R117H, and M470V genotyping was performed using PCR-RFLP method. ResultsIVS8-5T, IVS8-7T, IVS8-9T, and M470V alleles were found at the frequencies of 5.7, 75.5, 18.9, and 55.7%, respectively, while R117H was not observed. Among women, the severe form of the disease was more frequent in carriers of at least one IVS8 9T allele (RR for 9T/9T + 9T/non-9T vs. non-9T/non-9T: 2.115; 95% CI: 1.241–3.605). This association was not detected in men and was not affected by M470V. In addition, co-morbidities increased the severity of acute pancreatitis (p = 0.022). ConclusionOur study reveals that IVS8 poly-T variation affects severity of acute pancreatitis in women and that existent co-morbidities worsen the clinical course of the disease.

Comparison of clinical course of Acute Biliary and Non-Biliary Pancreatitis

Introduction: Incidence of acute pancreatitis (AP) varies in different parts of the world. The published data are mainly based on retrospective analysis of hospital admissions, which show that there are considerable geographical differences in the incidence rate. There are also regional divergences with regard to the etiology, and its impact on morbidity and mortality. Therefore, we compare the clinical course of acute biliary and non-biliary pancreatitis at the Tribhuvan University Teaching Hospital (TUTH) as well as we compare the morbidity and mortality and duration of hospital stay in these groups.
 Methods: This prospective study included the patients with a diagnosis of AP over a period of one year. Eighty-five patients with the diagnosis of AP were included in the study. Revised Atlanta classification system (2012) was used to diagnose and define the severity of disease. The occurrence of local and systemic complications, median duration of hospital stay and mortality in AP was studied.
 Results: Among 85 patients, 34 patients were females and 51 were males. Among them, 46 patients belonged to the biliary group and 39 belonged to the non-biliary group. Alcohol intake was the major etiology in the non-biliary group (n = 26) and all of them were male. The majority of the gallstone induced AP patients were female (n = 29). Twenty-nine patients developed severe acute pancreatitis (SAP: 16 in biliary and 13 patients in non-biliary group). Complications were mostly seen in SAP. The acute fluid collection was the most common local complication (15 patients in biliary and 15 patients in non-biliary group, p > 0.05) and respiratory failure was the most common systemic complication (18 patients in biliary and 16 patients in non-biliary group, p > 0.05) in both groups. Three patients in biliary group and four patients in non-biliary group died due to multi-organ failure (p > 0.05). There was no statistical significant difference in the median duration of hospital stay in these groups.
 Conclusion: Though pathogenesis vary for different etiologies, once the disease process has started, local complications, systemic complications, duration of hospital stay and mortality in AP depends on the severity of the disease irrespective of the etiology.

Pancreatitis in the Critical Care Setting

Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016. Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

Pancreatitis

Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016. Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay.

The 2012 revised Atlanta classification is an update of the original 1992 Atlanta classification, a standardized clinical and radiologic nomenclature for acute pancreatitis and associated complications based on research advances made over the past 2 decades. Acute pancreatitis is now divided into two distinct subtypes, necrotizing pancreatitis and interstitial edematous pancreatitis (IEP), based on the presence or absence of necrosis, respectively. The revised classification system also updates confusing and sometimes inaccurate terminology that was previously used to describe pancreatic and peripancreatic collections. As such, use of the terms acute pseudocyst and pancreatic abscess is now discouraged. Instead, four distinct collection subtypes are identified on the basis of the presence of pancreatic necrosis and time elapsed since the onset of pancreatitis. Acute peripancreatic fluid collections (APFCs) and pseudocysts occur in IEP and contain fluid only. Acute necrotic collections (ANCs) and walled-off necrosis (WON) occur only in patients with necrotizing pancreatitis and contain variable amounts of fluid and necrotic debris. APFCs and ANCs occur within 4 weeks of disease onset. After this time, APFCs or ANCs may either resolve or persist, developing a mature wall to become a pseudocyst or a WON, respectively. Any collection subtype may become infected and manifest as internal gas, though this occurs most commonly in necrotic collections. In this review, the authors present a practical image-rich guide to the revised Atlanta classification system, with the goal of fostering implementation of the revised system into radiology practice, thereby facilitating accurate communication among clinicians and reinforcing the radiologist's role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. (©)RSNA, 2016.

Lack Of PRSS1 And SPINK1 Polymorphisms In Serbian Acute Pancreatitis Patients

Abstract Acute pancreatitis represents an acute nonbacterial inflammation of the pancreas caused by a premature and ectopic activation of pancreatic digestive enzymes. Two of the most important genes in pancreatic autodigestion, PRSS1 and SPINK1, were implicated in the earliest discoveries of the genetic background of pancreatitis. However, the distribution of their variations displays interethnic variability, which could significantly affect the magnitude of their proposed effects on this disease worldwide. The aim of the present study was to investigate the distribution of the most important functional variations of PRSS1 (86A>T and 365G>A) and SPINK1 (101A>G), and their influence on the clinical course of acute pancreatitis in Serbian patients. The study enrolled 81 subjects, the severity of disease course was determined using the Atlanta Classification system, and the genotyping was conducted using a PCR-RFLP method. PRSS1 86A>T and 365G>A SNPs were not observed in the study population, while SPINK1 101A>G was present with the frequency of 0.62% (95% CI: 0.00, 3.83%). Due to extremely low frequencies or absences of examined variations, the proposed effect of these SNPs on the severity of acute pancreatitis could not be confirmed. The results do not support routine genotyping of either PRSS1 or SPINK1 in Serbs.

Imaging lexicon for acute pancreatitis: 2012 Atlanta Classification revisited.

The original 1992 Atlanta Classification System for acute pancreatitis was revised in 2012 by the Atlanta Working Group, assisted by various national and international societies, through web-based consensus. This revised classification identifies two phases of acute pancreatitis: early and late. Acute pancreatitis can be either oedematous interstitial pancreatitis or necrotizing pancreatitis. Severity of the disease is categorized into three levels: mild, moderately severe and severe, depending upon organ failure and local/systemic complications. According to the type of pancreatitis, collections are further divided into acute peripancreatic fluid collection, pseudocyst, acute necrotic collection, and walled-off necrosis. Insight into the revised terminology is essential for accurate communication of imaging findings. In this review article, we will summarize the updated nomenclature and illustrate corresponding imaging findings using examples.

Acute pancreatitis

Acute pancreatitis is an inflammatory condition with a variable clinical course. Diagnosis is based upon clinical presentation, laboratory indices and imaging studies, whilst illness severity can be assessed by clinical scoring systems, such as the Ranson, Glasgow or APACHE II criteria, or by radiological assessments such as the CT severity index. Most patients develop self-limiting disease but a minority progress to a severe form with both local and systemic complications. Management is usually non-operative with interventional therapy reserved for those with common bile duct stones or complications, such as walled-off necrosis or pseudocyst formation. This article will review the pathophysiology, assessment and treatment of acute pancreatitis, the revisions made to the Atlanta Classification system, and the surgical and non-surgical techniques for local complications.

NAFLD Diagnosed with Abdominal Ultrasound is a Marker of Severity in Acute Pancreatitis

Objective: Obesity, particularly metabolic obesity, is associated with an increased incidence and enhanced severity of acute pancreatitis (AP). Non Alcoholic Fatty Liver Disease (NAFLD) is a marker of metabolic obesity, which can be easily diagnosed, with the help of initial abdominal ultrasound (AUS) routinely performed in all patients with AP upon admission to assess a biliary etiology. The aim of this study is to identify the clinical utility of detecting NAFLD by AUS in determining the severity of patients with AP Methods: Five hundred and seventy four patients with non-alcoholic AP were divided into two groups on the basis of presence or absence of NAFLD detected by AUS at the time of admission. The diagnosis of NAFLD was based solely on imaging findings. Well-established single markers of prognosis as well as scoring systems were studied in both groups. The data was analyzed using the student's t-test, chi-square test and multivariate regression analysis. Results: Patients with NAFLD had a more severe disease as compared to patients without NAFLD as measured by single markers of prognosis like serum albumin, mean length of stay, ICU admission and mortality as well as scoring systems like BISAP score and Modified Atlanta Classification system ( P value < 0.05) BMI, by itself, was not associated with any difference in outcomes in patients with and without NAFLD as assessed by multivariate regression analysis. Age, sex and individual components of metabolic syndrome also had no influence on the prognostic markers Conclusion: Presence of NAFLD as diagnosed by early AUS can be used as an additional single marker of prognosis in AP. The diagnosis of NAFLD is objective and almost always available at the time of initial presentation of AP.

Necrotizing pancreatitis: diagnosis, imaging, and intervention.

Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.

Clinical relevance of the revised Atlanta classification focusing on severity stratification system

Background/ObjectiveRecognizing the limitation of the Atlanta classification for acute pancreatitis (AP), two international classifications have been recently proposed; the revised Atlanta classification and the determinant-based classification. There is an inconsistency between the two international classifications on whether infected necrosis (IN) is the major determinant of severity in AP. The aim of the current study was to validate the revised Atlanta classification and to determine the association of this new classification system with relevant clinical outcome in patients with AP. MethodsData have been collected on 553 patients with AP admitted to a single center during the 7-year period commencing January 2006. Primary outcomes included the need for interventions, the need for intensive care unit (ICU) care, length of ICU stay, total hospital stay, and mortality. ResultsThe different grades of severity for revised Atlanta classification system were associated with statistically significant differences in terms of clinical outcomes. Patients with severe AP that had IN, compared to those without IN, were associated with worse clinical outcomes. Having stratified patients with severe AP category according to the presence or absence of IN, the mortality rate increased fourfold to 32.3% for the presence of infected necrosis. ConclusionsOverall, the revised Atlanta classification seems to be valid, since it correlates well with clinical outcome. To more accurately assess clinical outcome of patients with severe AP defined by the revised Atlanta classification, however, severe AP patients with IN should be considered separately from those without IN in classification system.

Early phase of acute pancreatitis: Assessment and management.

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

Short term chemotherapy followed by RFA: A new protocol for stage III pancreatic cancer?

s / Pancreatology 12 (2012) 502–597 569 Aims/objectives: To determine whether or not there is a connection between the metabolic syndrome (MetS) and AP. Patients and methods: Medical histories of 178 patients diagnosed with AP during the years 2008 through 2010 were analyzed. The International Diabetes Federation (IDF) parameters were used in diagnosing MetS. The effect of MetS on AP was determined through the occurrence of local and/or systemic complications of AP, using the Atlanta classification system. The statistical analysis was performed using the Mann-Whitney U-Test and the c2-test. Results: Of the 178 patients, 93 patients suffered from MetS. The percentage of patients with distinct AP complications in the MetS vs. nonMetS group was 39.8 5.1% vs. 30.6 5.0% for local complications (p1⁄4.20) and 30.1 4.8% vs.16.4 4.0% for systemic complications (p1⁄4.03). When the groups were subdivided according to the number of complications into two subgroups (first with only one and the second with multiple complications), it was noted that the MetS patients more often suffered from multiple complications compared to patients without MetS. Again, this was statistically significant for systemic complications (p1⁄4.024), but not for local ones. Conclusion: The presence of MetS seems to coincide with the occurrence of systemic complications of AP, especially in the case of multiple systemic complications.