Extent Of Pancreatic Necrosis Research Articles

Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis—a single-center randomized study

Pancreatic infection is the main indication for surgery and the principal determinant of prognosis in acute necrotizing pancreatitis. Previous studies on the effects of antibiotics have not, however, uniformly demonstrated any reduction in the need for surgery or any decrease in mortality among these patients, although the incidence of pancreatic infections was significantly reduced. This single-center randomized study was designed to compare early vs. delayed imipenem treatment for acute necrotizing pancreatitis. Ninety patients with acute necrotizing pancreatitis (C-reactive protein > 150 mg/L, necrosis on CT) were randomized within 48 hours either to a group receiving imipenem (1.0 g plus cilastatin intravenously 3 times a day) or a control group. Not included were those who had been started on antibiotics at the referring clinic, those who were taken directly to the intensive care unit for multiorgan failure, and those who refused antibiotics or might have had adverse reactions. Thirty-two patients were excluded because they were over 70 years of age (not potentionally operable) or for any study violation. There were 25 patients in the imipenem group and 33 patients in the control group. The main end point was the indication for necrosectomy due to infection (i.e., after the initial increase and decrease, there was a second continuous increase in temperature, white blood cell count [30%] and C-reactive protein [30%], with other infections ruled out, or bacteria were found on Gram stain of the pancreatic fine-needle aspirate). In the control group, imipenem was started when the operative indication was fulfilled. Conservative treatment was continued for at least 5 days before necrosectomy. The study groups did not differ from each other with regard to sex distribution, patient age, etiology, C-reactive protein concentration, and extent of pancreatic necrosis on CT. Two (8%) of 25 patients in the imipenem group compared to 14 (42%) of 33 in the control group fulfilled the operative indications ( P = 0.003). Nine patients in the control group responded to delayed antibiotics but five had to undergo surgery. Of those receiving antibiotics, 2 (8%) of 25 in the early antibiotic (imipenem) group needed surgery compared to 5 (36%) of 14 in the delayed antibiotic (control) group ( P = 0.04). Two (8%) of 25 patients in the imipenem group and 5 (15%) of 13 patients in the control group died ( P = NS [no significant difference]). Seven (28%) of 25 in the imipenem group and 25 (76%) of 33 in the control group had major organ complications ( P = 0.0003). Based on the preceding criteria, early imipenem-cilastatin therapy appears to significantly reduce the need for surgery and the overall number of major organ complications in acute necrotizing pancreatitis, and reduces by half the mortality rate; this is not, however, statistically significant in a series of this size.

Management of acute pancreatitis: a comparative audit of clinical practice against the recommendations of the british society of gastroenterology

AIMS: In 1998 the British Society of Gastroenterology (BSG) published national guidelines for the management of acute pancreatitis (AP) in an attempt to improve diagnosis and reduce mortality rates. A comparative audit was undertaken of the management of AP against the BSG recommendations. METHODS: A retrospective analysis of 53 patients (median age 61 (range 24-95) years) admitted with AP during 1998 was undertaken and a comparison was made with the BSG guidelines. RESULTS: Some 70 per cent (n = 37) of the patients were admitted with mild AP and 30 per cent (n = 16) with severe AP. The BSG recommendations are shown in parentheses in the following text. The overall mortality rate was 17 per cent (less than 10 per cent), zero in mild AP and 56 per cent in patients with severe AP (less than 30 per cent). A correct diagnosis of AP was made within 48 h of admission in all patients (100 per cent). Severity stratification within 48 h using the Glasgow criteria and C-reactive protein (CRP) level, as suggested by the BSG, was done in approximately 80 per cent of patients. Table 1. CRP was measured in 51 per cent of the patients within the first 4 days (100 per cent) and at the end of the first week (100 per cent). Gallstones and alcohol counted for 72 per cent of causes of AP and the aetiology was determined in 77 per cent (75-80 per cent). All patients with severe AP were managed in a high-dependency or intensive therapy unit with central venous pressure monitoring and prophylactic intravenous antibiotics, and underwent dynamic computed tomography within 3-10 days of admission (100 per cent). Some 86 per cent of patients with suspected common bile duct (CBD) stones (jaundice, deranged liver function tests, dilated CBD) underwent endoscopic retrograde cholangiopancreatography with or without duct drainage and clearance. CONCLUSIONS: Management of AP closely mirrors the BSG guidelines, but fails to fully address severity stratification with respect to LDH, CRP and PaO2 at 48 h. A thorough analysis of patients with severe AP (i.e. extent of pancreatic necrosis, onset of infection) has been undertaken to explain the mortality rate and it is proposed to prospectively audit admissions with AP in 1999 in order to close the audit loop.

Pancreatitis: computed tomography and magnetic resonance imaging.

The value of CT in management of severe acute pancreatitis is well established. Some, but not all, experimental studies suggest a detrimental effect of intravenous iodinated contrast agents in acute pancreatitis, but although initial clinical data tends to support this, the positive advantages of enhanced CT outweigh the possible risks. Magnetic resonance imaging has been shown to be as effective as CT in demonstrating the presence and extent of pancreatic necrosis and fluid collections, and probably superior in indicating the suitability of such collections for percutaneous drainage. Image-guided intervention remains a key approach in the management of severely ill patients, and the indications, techniques and results of radiological intervention are reviewed herein. Both CT and MRI can be used to diagnose advanced chronic pancreatitis, with the recent addition of MRCP as a viable alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP). Both MRCP and CT/MR imaging of the pancreatic parenchyma still have limitations in the recognition of the earliest changes of chronic pancreatitis--for which ERCP and tests of pancreatic function remain more sensitive--but the clinical significance of these minor changes remains contentious.

Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.

The risk factors predisposing to organ failure in patients with necrotizing pancreatitis remain unclear. The relationship between the extent of pancreatic necrosis, the presence of infection and the incidence of organ failure was analysed. In a retrospective review, the occurrence of pulmonary insufficiency, renal insufficiency, shock, sepsis/sepsis-like syndrome (SLS) and coagulopathy was evaluated in 273 patients with necrotizing pancreatitis, and a comparison was made between patients with sterile or infected necrosis. Additionally, the relation between the incidence of organ failure and extent of pancreatic parenchymal necrosis was investigated by classifying the patients into three groups according to the amount of necrotic tissue found by contrast-enhanced computed tomography (group 1, extent less than 30 per cent; group 2, 30-50 per cent; group 3, more than 50 per cent). Organ failure was more frequent in patients with infected necrosis than in those with sterile necrosis. Differences were found in the incidence of pulmonary insufficiency, sepsis/SLS and coagulopathy. Organ failure occurred more frequently in group 3 than in group 2 or 1 (95 versus 79 and 66 per cent; P = 0.0004). The extent of infected necrosis was not related to the incidence of organ failure (group 1, 88 per cent; group 2, 86 per cent; group 3, 96 per cent). However, there was a relation between the incidence of organ failure and the extent of sterile necrosis (group 1, 59 per cent; group 2, 74 per cent; group 3, 94 per cent; P = 0.0001). Multivariate analysis confirmed the presence of infection and the extent of necrosis as independent determinants of organ failure. The incidence of organ failure is determined by both bacterial infection and extent of necrosis. The incidence of organ failure is determined by the extent of necrotic parenchyma in patients with sterile necrosis. Infected necrosis is associated with a high incidence of organ failure irrespective of the extent of necrosis.

The management of severe acute necrotising pancreatitis: an evidence-based review of the literature.

Clearly the main determinant of outcome in severe acute pancreatitis is the extent of pancreatic necrosis and the subsequent risk for the development of infected necrosis. A thorough assessment using appropriate scoring systems and the early use of dynamic contrast-enhanced CT will highlight those patients likely to benefit from higher dependency or intensive care. Despite numerous suggested specific therapies there is still no Grade A evidence that any confers a significant mortality benefit. However, general supportive measures should include vigorous replacement of fluid losses to correct the circulating volume, correction of electrolyte and glucose abnormalities, and respiratory, cardiovascular and renal support as necessary. Those patients with infected pancreatic necrosis or deteriorating organ systems should undergo surgery. Patients with sterile necrosis should receive a broad-spectrum prophylactic antibiotic which adequately penetrates pancreatic tissue. Due attention should also be paid to nutritional support, for which a jejunal feeding tube with EN is recommended as early as is achievable.

Acute Pancreatitis

In this article we describe the current status of treatment of acute pancreatitis in Japan and the guidelines established for the treatment of severe acute pancreatitis. In 1987 the Research Committee for Intractable Diseases of the Pancreas of the Ministry of Health and Welfare conducted a nationwide survey on acute pancreatitis to determine the prevalence of the disease between 1982 and 1986 and the treatment modalities used. Based on a detailed assessment of the results of the survey, the Committee developed criteria for rating the severity of acute pancreatitis and guidelines for the treatment of acute pancreatitis, which was revised in 1995. The five points cited as the principal aspects of treatment of severe acute pancreatitis in Japan include (a) rating the severity of the disease according to the severity rating criteria; (b) differentiating between edematous and necrotic pancreatic lesions and performing dynamic CT of the pancreas to define the extent of pancreatic necrosis; (c) performing ultrasonography to determine whether there are gallstones; (d) in principle, not performing surgery except in patients who clearly have early infection or complications after the onset; and (e) providing conservative intensive care immediately after the onset. In the absence of complications, the treatment of acute pancreatitis in Japan is primarily medical. In contrast to other countries, however, administration of antiprotease agents has become an important method of treating acute pancreatitis in Japan. Special treatment modalities, such as peritoneal lavage, blood purification, and continuous arterial infusion of protease inhibitor, are being performed in severe acute pancreatitis, in addition to intensive care.

LDH to AST ratio in biliary pancreatitis—a possible indicator of pancreatic necrosis: Preliminary results

Lactate dehydrogenase (LDH) has been reported to be a sensitive indicator of pancreatic necrosis (PN). In patients with biliary pancreatitis (BP), however, liver enzymes are generally elevated early in the course of the disease because of acute inflammatory liver cell injury caused by ampullary stones impacted during their transpapillary passage. Accordingly, the identification of PN using the initial high LDH activity as an indicator of PN in BP may not be accurate. In patients with ongoing PN, LDH would be expected to increase thereafter. We hypothesized that an elevation of the ratio of LDH to aspartate aminotransferase (AST) (LDH/AST) would better reflect PN in BP. The plasma concentrations of the LDH/AST ratio over a 3-wk postadmission period were evaluated and compared with serial computed tomograpy (CT) scans of the abdomen in two groups of patients with BP, consisting of 5 PN patients and 17 non-PN patients. A group of 50 healthy adults served as controls for the LDH/AST ratio measurement. On postadmission days 1 and 2, the LDH/AST ratios in both groups of patients were low, with no significant difference. In the PN patients, the LDH/AST ratio increased thereafter, reached peak values, and decreased. In the non-PN patients, the LDH/ AST ratio increased gradually, but remained within the control range. In the PN patients, the LDH/AST ratios on postadmission days 3, 5, and 7 were significantly higher than those of the non-PN patients. The CT scans of the abdomen of the PN patients showed an initial edematous pancreas with the development of late PN. The peak values of the LDH/AST ratio correlated well with the extent of PN. An elevated LDH/ AST ratio identifies patients who develop PN. The LDH/ AST ratio could be used as an indicator of PN in BP patients.

Protective action of luminal bile salts in necrotizing acute pancreatitis in mice.

Bile salts in the intestinal lumen act to inhibit the release of cholecystokinin (CCK). Recent studies have shown that CCK may play a permissive role in the development of acute pancreatitis. In this study, the amount of luminal bile salts in female Swiss Webster mice was either decreased by feeding 4% (wt/wt) cholestyramine or increased by feeding 0.5% sodium taurocholate for 1 wk. Plasma levels of CCK were stimulated by cholestyramine and inhibited by taurocholate. Then, acute pancreatitis was induced either by caerulein injections, or by feeding a choline-deficient, ethionine-supplemented (CDE) diet. Feeding of cholestyramine significantly decreased survival from 25% to 0% in the CDE pancreatitis, and increased the magnitude of elevation of serum amylase levels and the extent of pancreatic necrosis in both models of pancreatitis; CCK-receptor blockade with CR-1409 completely abolished the adverse effects of cholestyramine. In contrast, feeding of taurocholate significantly increased survival to 100% and decreased the elevation of serum amylase and pancreatic necrosis; CCK-8 antagonized these actions of taurocholate. Luminal bile salts appear to provide a physiologic protection against necrotizing pancreatitis, at least in part, both by inhibiting the release of CCK and by promoting resistance of the pancreas to CCK excessive stimulation in vivo.

Zur Wertigkeit der Nativ-Computertomographie bei der akuten Pankreatitis

The value of non contrast computed tomography for the early diagnosis and staging of acute pancreatitis has been investigated in 90 patients. The volume of the pancreas and of extra-pancreatic inflammatory infiltrates was statistically significantly larger in necrotising pancreatitis than in interstitial pancreatitis. The extent of intrapancreatic hypodensity (below 40 HU) showed no significant correlation with the pathologically determined extent of pancreatic necrosis. Densitometry of the extrapancreatic infiltrate indicates its nature with considerable accuracy (oedematous-inflammatory or haemorrhagic-necrotising).