Ranson Criteria Research Articles

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II scoring system in predicting acute pancreatitis outcome

Acute pancreatitis (AP) is a process with variable involvement of regional tissues or organ systems. Multifactorial scales included the Ranson, Acute Physiology and Chronic Health Evaluation (APACHE II) systems and Balthazar computed tomography severity index (CTSI). The purpose of this review study was to assess the accuracy of CTSI, Ranson score, and APACHE II score in course and outcome prediction of AP. We reviewed 121 patients who underwent helical CT within 48 h after onset of symptoms of a first episode of AP between 1999 and 2003. Fourteen inappropriate subjects were excluded; we reviewed the 107 contrast-enhanced CT images to calculate the CTSI. We also reviewed their Ranson and APACHE II score. In addition, complications, duration of hospitalization, mortality rate, and other pathology history also were our comparison parameters. We classified 85 patients (79%) as having mild AP (CTSI <5) and 22 patients (21%) as having severe AP (CTSI > or =5). In mild group, the mean APACHE II score and Ranson score was 8.6+/-1.9 and 2.4+/-1.2, and those of severe group was 10.2+/-2.1 and 3.1+/-0.8, respectively. The most common complication was pseudocyst and abscess and it presented in 21 (20%) patients and their CTSI was 5.9+/-1.4. A CTSI > or =5 significantly correlated with death, complication present, and prolonged length of stay. Patients with a CTSI > or =5 were 15 times to die than those CTSI <5, and the prolonged length of stay and complications present were 17 times and 8 times than that in CTSI <5, respectively. CTSI is a useful tool in assessing the severity and outcome of AP and the CTSI > or =5 is an index in our study. Although Ranson score and APACHE II score also are choices to be the predictors for complications, mortality and the length of stay of AP, the sensitivity of them are lower than CTSI.

The Optimal Timing of Laparoscopic Cholecystectomy in Mild Gallstone Pancreatitis

The optimal timing of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis is not standardized. Our objective was to determine if patients with mild gallstone pancreatitis (three or fewer Ranson's criteria) can safely proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving. We reviewed the charts of all adults admitted to our institution with gallstone pancreatitis from January 1999 until June 2002 who had LC performed by either surgeon 1 (group 1) or surgeon 2 (group 2). Surgeon 1 preferred to delay surgery until normalization of amylase and complete resolution of abdominal tenderness, whereas surgeon 2 preferred to proceed to LC as soon as serum amylase was decreasing and abdominal tenderness was improving. The two groups were well matched for sex, age, Ranson's criteria, and percentage requiring endoscopic retrograde cholangiopancreatography. Average total hospital stay was 4.7 days in group 1 versus 3.5 days in group 2 (P = 0.01). There was no statistical difference in complication rate between the two groups (10% in group 1 vs 11% in group 2, P = 0.12). The data suggest that hospital stay can be shortened with no increased complication rate if patients with mild biliary pancreatitis proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving.

Effect of carbon dioxide pneumoperitoneum on the severity of acute pancreatitis: An experimental study in rats

In the management of mild acute biliary pancreatitis, it is generally recommended to perform laparoscopic cholecystectomy after the subsidence of the attack during the same hospital admission. The effect of laparoscopy on abdominal organs has been widely investigated but not in acute pancreatitis. This study used an animal model of mild acute pancreatitis to examine the effects of CO(2) pneumoperitoneum on acute pancreatitis in rats. Mild acute pancreatitis was induced in 30 male Sprague-Dawley rats by surgical ligation of the biliopancreatic duct. After 2 days, animals were assigned to three groups: sham operation (animals were anesthetized for 30 min without undergoing laparotomy), CO(2) pneumoperitoneum (applied for 30 min at a pressure of 12 mmHg), and laparotomy (performed for 30 min, and then the abdomen was closed). Two hours after the surgical procedures, animals were killed and levels of lactate dehydrogenase, aspartate aminotransferase, glucose, urea, hematocrit, and leukocyte count among Ranson's criteria and levels of amylase, lipase, and total bilirubin were measured to determine the severity of acute pancreatitis. Histopathologic examination of the pancreas was done, and malondialdehyde and glutathione levels of the pancreas and lung were determined. The only significant differences between the groups were in lactate dehydrogenase and aspartate aminotransferase levels, which were significantly higher in the pneumoperitoneum group compared to the sham operation group. CO(2) pneumoperitoneum for 30 min at a pressure of 12 mmHg did not affect the severity of acute pancreatitis induced by ligation of the biliopancreatic duct in rats.

Acute biliary pancreatitis: when should the endoscopist intervene?

A 63-year-old usman is admitted to the hospital with acute pancreatitis of presumed biliary origin. Laboratory results include white blood cell count (WBC) 18,500; hemoglobin 13.0; platelets 191,000; alanine aminotransferase (ALT) 330; aspartate aminotransferase (AST) 260; alkaline phosphatase 250; bilirubin 1.4; glucose 225; blood urea nitrogen (BUN) 47; creatinine 1.4; and prothrombin time 12 seconds. Ultrasound shows gallstones in the gallbladder; the common bile duct is 5 mm without stones identified.

Pancreatitis in HIV infection: predictors of severity

Objectives Acute pancreatitis occurs at greater frequency in HIV-infected patients than in the general population. We set out to determine the frequency of severe acute pancreatitis in HIV-positive patients and to study the accuracy of The Acute Physiology and Chronic Health Evaluation (APACHE II), Ranson, and Glasgow scales for prediction of clinical disease severity. Methods A total of 73 HIV-infected patients with acute pancreatitis were identified retrospectively. Demographic and clinical parameters as well as clinical outcomes were established. Sensitivities and specificities of the three scales mentioned above were calculated and compared. Results Of the patients, 63 (83.6%) had AIDS. The majority of cases were medication-induced (46%) or idiopathic (26%). The incidence seemed to be declining in the late 1990s. Eleven patients (15%) had a severe course as defined by death, admission to the intensive care unit, or local complications requiring surgery. Eighteen case (24.6%) were considered severe as defined by the criteria established at the International Symposium on Acute Pancreatitis in Atlanta in 1992. APACHE II criteria best predicted outcome with an overall accuracy of 75% (Glasgow 69%, Ranson 48%). Maximal accuracy was achieved with cut-offs of 14 for APACHE II and 4 for the Glasgow and Ranson criteria. Conclusions HIV-infected patients have a clinical outcome similar to that of the general population. Clinical predictive scales are applicable and useful in this population.

Timing of cholecystectomy for acute biliary pancreatitis: outcomes of cholecystectomy on first admission and after recurrent biliary pancreatitis.

Biliary stones are the leading cause of acute pancreatitis. Although cholecystectomy and selective endoscopic retrograde cholangiography (ERC) comprise the current treatment in patients with acute biliary pancreatitis (ABP), the time of intervention is still controversial. In this study we evaluated the outcomes of cholecystectomy on first admission for ABP and in patients with recurrent biliary pancreatitis. A series of 43 patients with ABP between January 1997 and November 2000 were evaluated retrospectively. Patients were classified into two groups. Group I included 27 patients who underwent cholecystectomy on first admission before discharge from the hospital. Group II comprised 16 patients who had recurrent biliary pancreatitis and then underwent cholecystectomy. The severity of the pancreatitis was determined by Ranson's criteria. Age, gender, length of hospital stay, severity of pancreatitis, amylase level, and complications of cholecystectomy were evaluated in both groups. Patients in group I underwent cholecystectomy during the original hospital admission and patients in group II during an admission for a recurrence. There were 24 patients with a Ranson's score </= 3 in group I and 12 in group II. The mean hospital stays were 15.29 days (range 4-48 days) and 36.66 days (range 15-123 days) in groups I and II, respectively ( p = 0.006). Morbidity was 11% without mortality in group I and 43% with one mortality in group II ( p = 0.023). Definitive treatment of ABP can be accomplished effectively and safely by cholecystectomy following clinical improvement, with selective ERC performed during the first admission (delayed cholecystectomy). Waiting to perform cholecystectomy (interval cholecystectomy) may result in recurrent biliary pancreatitis, which may increase morbidity and the length of the hospital stay.

The Usefulness of Laboratory Tests in the Early Assessment of Severity of Acute Pancreatitis

Acute pancreatitis is a disorder that affects approximately 200,000 individuals in the U.S. annually. While most cases are mild, up to 30% of patients will have a complicated course with prolonged hospitalization and significant morbidity and mortality. Early institution of several therapeutic interventions, such as enteral nutrition, prophylactic antibiotics, endoscopic retrograde cholangiopancreatography (ERCP) and intensive care monitoring, have been shown to decrease the morbidity associated with severe acute pancreatitis. However, the ability of clinicians to predict, upon presentation, which patient will have mild or severe pancreatitis has remained poor over the years, thus leading to a delay in the institution of such treatments. Researchers have focused on markers that might improve upon clinical prediction alone. While data have shown the predictive value of tools such as Ranson's and Glasgow's criteria, C-reactive protein (CRP) and the APACHE score, their application in clinical practice has been limited by a time delay of at least 48 h in the former two and by being cumbersome in the latter. Thus, our focus is to critically appraise the evidence available for various biochemical markers in their ability to distinguish mild and severe acute pancreatitis early and more accurately than currently available tools.Referee: Dr. James H. Grendell, Winthrop Univ Hospital, Div of Gastroenterology, Hepatology & Nutrition, 222 Station Plaza, #429, Mincola, NY 11501, USA. Tel:516-663-2528. Fax:516-663-4617. E-mail:jgrendel@winthrop.org

Prognostic indicators in acute pancreatitis.

Several approaches have been used in an attempt to predict the severity and prognosis of attacks of acute pancreatitis. The Ranson and Glasgow criteria include a variety of simple laboratory parameters that are measured on admission and again within 48 h. They are the most widely used indices in clinical practice. The Acute Physiological and Chronic Health Evaluation II system is more complicated, but can be applied to a wide variety of conditions, especially in intensive care settings. The usefulness of this system depends on the threshold score for defining severe pancreatitis; a score of eight appears to be the most appropriate. The finding of nonperfused areas in the pancreas at contrast-enhanced computed tomography is indicative of pancreatic necrosis and portends an unfavourable prognosis. Other clinical and laboratory indices have been proposed, but the most important predictive factor of early mortality seems to be the presence and persistence of a Marshall organ failure score of two or more. This is especially true if organ dysfunction persists beyond 36 h. Radiological findings do not always correlate well with the presence of organ dysfunction, and more investigations are required.

Improved prediction of outcome in patients with severe acute pancreatitis by the APACHE II score at 48 hours after hospital admission compared with the APACHE II score at admission. Acute Physiology and Chronic Health Evaluation.

The 48-hour APACHE (Acute Physiology and Chronic Health Evaluation) II score is a better predictor of pancreatic necrosis, organ failure, and mortality in patients with severe acute pancreatitis than the score at hospital admission. A retrospective analysis of 125 patients with acute pancreatitis. A tertiary public teaching hospital. Patients with severe acute pancreatitis as defined by 3 or more Ranson criteria or a hospital stay of longer than 6 days. Pancreatic necrosis, organ failure, and mortality. A significant association was found between the 48-hour score and the presence of pancreatic necrosis (P<.001), organ failure (P =.001), and death (P<.001). By contrast, the APACHE II score at admission was significantly associated only with the presence of organ failure (P =.007). Deteriorating APACHE II scores over 48 hours were significantly associated with a fatal outcome (P =.03). The combined APACHE II score (defined as the sum of the admission and 48-hour scores) was significantly higher among nonsurvivors than survivors (P<.001), and was strongly associated with the presence of pancreatic necrosis (P =.001) and organ failure (P<.001). The 48-hour and combined scores accurately predicted outcome in 93% of the patients compared with 75% by the admission score. The 48-hour APACHE II score has improved predictive value compared with the admission score for identifying patients with severe acute pancreatitis who have a poor outcome. A deteriorating APACHE II score at 48 hours after admission may identify patients at risk for an adverse outcome.

Urinary trypsinogen activation peptide is more accurate than hematocrit in determining severity in patients with acute pancreatitis: a prospective study

OBJECTIVE: The management of patients with acute pancreatitis is complicated by the inability to distinguish mild from severe disease during the early stages. It has been previously shown that urinary trypsinogen activation peptide (TAP) and hematocrit (Hct) may serve as early predictors of severity in patients with acute pancreatitis. To establish which marker is more accurate in the determination of severity in patients with acute pancreatitis, a prospective study was performed. METHODS: A consecutive series of patients admitted with pain consistent with acute pancreatitis and an amylase of three times the upper limit of normal were included. The admission and 24-h Hct was obtained. A urine sample was obtained within 12 h of admission. Urinary TAP was determined using a modified solid phase ELISA. Severity was defined by the Atlanta Symposium, as the presence of organ failure and/or pancreatic necrosis. RESULTS: Fifty-eight consecutive patients with acute pancreatitis participated. There were 33 men and 25 women with a mean age of 60 ± 19. Thirty-nine patients had mild disease; 19 had severe disease. Urinary TAP was elevated in 26 patients. All patients with severe pancreatitis were correctly identified as having severe disease by an elevated urinary TAP (sensitivity 100%, specificity 77%). The admission Hct was higher than 47 in only three patients, all with mild disease. Of the patients with a rise in Hct, eight had mild disease, and only one had severe disease. Using a Hct of 44 as a cutoff did not affect the accuracy. There was no association between a rise in Hct and failure of Hct to decrease in the determination of severity. CONCLUSIONS: In comparison to admission Hct, urinary TAP was more accurate in determining severity in patients with acute pancreatitis by Atlanta, APACHE II, and Ranson criteria. We conclude that urinary TAP is a more accurate predictor of severity in patients with acute pancreatitis compared with Hct. Urinary TAP should be used to determine severity in patients early in the course of acute pancreatitis.

Urinary trypsinogen activation peptide is more accurate than hematocrit in determining severity in patients with acute pancreatitis: a prospective study.

The management of patients with acute pancreatitis is complicated by the inability to distinguish mild from severe disease during the early stages. It has been previously shown that urinary trypsinogen activation peptide (TAP) and hematocrit (Hct) may serve as early predictors of severity in patients with acute pancreatitis. To establish which marker is more accurate in the determination of severity in patients with acute pancreatitis, a prospective study was performed. A consecutive series of patients admitted with pain consistent with acute pancreatitis and an amylase of three times the upper limit of normal were included. The admission and 24-h Hct was obtained. A urine sample was obtained within 12 h of admission. Urinary TAP was determined using a modified solid phase ELISA. Severity was defined by the Atlanta Symposium, as the presence of organ failure and/or pancreatic necrosis. Fifty-eight consecutive patients with acute pancreatitis participated. There were 33 men and 25 women with a mean age of 60 +/- 19. Thirty-nine patients had mild disease; 19 had severe disease. Urinary TAP was elevated in 26 patients. All patients with severe pancreatitis were correctly identified as having severe disease by an elevated urinary TAP (sensitivity 100%, specificity 77%). The admission Hct was higher than 47 in only three patients, all with mild disease. Of the patients with a rise in Hct, eight had mild disease, and only one had severe disease. Using a Hct of 44 as a cutoff did not affect the accuracy. There was no association between a rise in Hct and failure of Hct to decrease in the determination of severity. In comparison to admission Hct, urinary TAP was more accurate in determining severity in patients with acute pancreatitis by Atlanta, APACHE II, and Ranson criteria. We conclude that urinary TAP is a more accurate predictor of severity in patients with acute pancreatitis compared with Hct. Urinary TAP should be used to determine severity in patients early in the course of acute pancreatitis.

Serum Profiles of Interleukin-18 in Different Severity Forms of Human Acute Pancreatitis

Background: Interleukin 18 (IL-18) is a new mediator and modulator of the immune response; its role in acute pancreatitis (AP), however, has not yet been fully explained. The aim of our study was to evaluate the profile IL-18 serum concentrations in the course of acute pancreatitis. Methods: The prospective study involves 30 patients with AP ( n = 15 with mild AP and n = 15 with severe AP) as well as 10 healthy subjects. AP severity was defined according to Ranson's and Balthazar's criteria, supplemented by serum CRP concentration measurements. In the course of hospitalization, 2 patients with severe AP died. Serum IL-18 and plasma polymorphonuclear leukocyte elastase (PMN-E) concentrations were measured at admission (day 1) and on days 2, 3, 5 and 10. Results: In both the mild and the severe forms of AP, serum IL-18 concentration was significantly higher than in the healthy controls. In severe AP, serum IL-18 reached the highest levels in all observed periods compared to that in patients with mild AP. Significant correlations, calculated for day 1, were found between serum IL-18 and plasma PMN-E (Rs = 0.514, P < 0.001) and between IL-18 and CRP (Rs = 0.463, P < 0.001) levels. Conclusions: Serum profile IL-18 during AP indicates that this cytokine was released early after AP onset and may play the key role in inflammatory and immune response. Positive correlation between serum IL-18 and commonly known early prognostic markers of AP severity suggest that serum IL-18 concentrations may represent another early marker indicating severe course of AP.

Treatment of Gallstone Pancreatitis: Six‐year Experience in a Single Center

Acute pancreatitis (AP) is a complicated disease in 20% to 25% of cases and carries a mortality of 8% to 15%. Etiologically, the most frequent form is acute biliary pancreatitis. Treatment of such an entity is still controversial, but minimally invasive techniques undoubtedly play an important role. We retrospectively analyze our cases of AP observed from January 1992 to May 1998. Etiology was biliary in 95/125 (76%) cases. In 90 cases we evaluated the patient within a few hours of the onset of symptoms. According to the Ranson criteria, we observed a mild form in 74/90 (82.2%) cases and a severe form in 16/90 (17.8%) cases. Our standard policy was to perform urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy followed by elective laparoscopic cholecystectomy. In particular clinical settings, other modalities of treatment were employed, such as percutaneous cholecystostomy and percutaneous drainage of fluid collections. Successful ERCP was performed in 86/90 cases (95.5%). The procedure was performed in an emergency setting (within 48 hours) in 62/90 cases (68.9%). Whenever the patient was a candidate for surgery, cholecystectomy was performed, laparoscopically in 67/90 cases (74.4%) and via laparotomy in 7/90 cases (7.8%). In only two cases was pancreatic necrosectomy necessary. Globally, we observed a low procedure-related morbidity (6.7%) and no mortality. In the setting of acute biliary pancreatitis, regardless of the severity of the attack, an urgent ERCP + endoscopic sphincterotomy followed by laparoscopic cholecystectomy is safe and could enable successful management of the patient. Associated morbidity and mortality were low. In addition, when indicated, it is possible to treat a great number of concomitant complications with percutaneous ultrasound-guided drainage.

Enterale Ernährung bei akuter Pankreatitis

The metabolism of acute pancreatitis is characterized by hypermetabolism and catabolism. Evidence for glucose intolerance occurs in anywhere from 40 to 90% of cases and urine urea nitrogen may increase up to 40 g/day. The most important aspect when considering nutritional therapy is determining the severity of the pancreatitis. The APACHE-II-scoring-system and the time honored Ranson criteria are useful for differentiating severe from mild pancreatitis. Despite some limitations in sensitivity and specificity, studies have suggested that patients with 2 or less Ranson criteria and an APACHE-II-score of 9 or less have mild pancreatitis, while patients with 3 or more Ranson criteria and an APACHE-II-score of 10 or more have severe pancreatitis. Evidence of organ failure on clinical presentation and pancreatic necrosis on dynamic CT scan are also important factors in determining severity of pancreatitis and are probably the two major indicators of patient outcome. Only 3 prospective randomized controlled trials have compared enteral to parenteral nutrition for pancreatitis. All studies described successful use of enteral feeding without exacerbating the disease process although a mild stimulation of exocrine pancreatic secretion could not be prevented, even when the tube was placed below the ligament of Treitz. Kalfarentzos [11] and McClave [14] could show that hyperglycemia was worse in the parenteral feeding patients compared to the enteral feeding group and Windsor [24] concluded with respect to the results of his study, that enteral feeding modulates the inflammatory response in acute pancreatitis. Conclusions regarding the use of enteral or parenteral nutrition in acute pancreatitis are difficult to form, as there is a need of more prospective studies. As ileus may be a problem in patients with greater severity of pancreatitis, limiting the application of early enteral feeding, the route of nutritional support should be determined by the clinical course and the severity of the disease.

Visceral pseudoaneurysms due to pancreatic pseudocysts: Rare but lethal complications of pancreatitis

Objective: Erosion of pancreatic pseudocysts into adjacent vessels is a rare but highly lethal cause of intra-abdominal hemorrhage. Percutaneous angiographic embolization (PAE) of the bleeding artery has recently been advocated as the preferred therapy. This study was undertaken to survey the outcome after treatment of this complication and to make recommendations for its management. Methods: An 11-year retrospective analysis was performed of all patients treated at a large tertiary care referral center for visceral artery pseudoaneurysms associated with pancreatic pseudocysts. Results: From 1988 to 1998, 256 patients were admitted for complications of pancreatic pseudocysts. Sixteen patients (11 men and 5 women) were identified in whom a pseudocyst had eroded into a major blood vessel with hemorrhage or development of a false aneurysm. The mean age was 45 years (range, 23-67 years). Active bleeding was present in 13 patients, whereas three had evidence of recent hemorrhage. Ten of 16 patients initially underwent operative therapy, four elective and six emergency, whereas six stable patients were initially treated with PAE. Technical failures of the initial treatment or secondary complications required both therapeutic modalities in six patients, which resulted in 13 total surgical interventions and 10 PAEs. The surgical morbidity rate was 62% (8 of 13), whereas that of PAE was 50% (5 of 10). Three deaths occurred after emergency operations, two of which failed to stop the bleeding, accounting for all of the deaths in the series (3 [19%] of 16). A trend was noted toward increased death with necrotizing pancreatitis (P =.07) and emergency surgery (P =.06). Ranson's criteria were not found to be predictive of death in this series. Surgical drainage procedures were required in seven (44%) of 16 patients for infections (n = 3) or mass effect of the pseudoaneurysm (n = 3). The mean size of pseudoaneurysms that required operative intervention for secondary complications was 13.9 cm, compared with 7.7 cm for all others in the series (P =.046). Long-term follow-up was available in all 13 survivors at a mean of 44 months (range, 1-108 months). Conclusions: The management of pancreatic pseudocyst-associated pseudoaneurysms remains a challenging problem with high morbidity and death rates. Operation and PAE play complementary management roles. PAE is recommended as the initial therapy for hemodynamically stable patients. Surgery should be reserved for actively bleeding, hemodynamically unstable patients; for failed embolization; and for other secondary complications such as infection or extrinsic compression. (J Vasc Surg 2000;32:722-30.)

Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA.

The aim of this study was to evaluate the incidence, pathogenesis, and prognosis of acute pancreatitis (AP) in diabetic ketoacidosis (DKA). DKA is associated with nonspecific increase in serum amylase levels. Autopsy studies, on the other hand, had previously raised the issue of pancreatic necrosis in patients with DKA. However, the incidence, pathogenesis and prognosis of AP in the setting of DKA has not been prospectively evaluated. This is a prospective evaluation of 100 consecutive episodes of DKA during a period of 13 months starting in January 1998, in a university hospital in New York City. In addition to careful history, complete blood count, arterial blood gas estimation, and a comprehensive metabolic assay, serum amylase, lipase, and triglyceride levels were estimated on admission and 48 h later. All patients with abdominal pain or elevated serum levels of amylase or lipase (more than three times normal) or triglyceride levels >5.65 mmo/L (500 mg/dl) had a CT scan of the abdomen. The diagnosis of AP was confirmed when pancreatic enlargement or necrosis on contrast enhanced CT scan was seen. Eleven patients (11%) had AP. History of abdominal pain, not a feature on admission to include AP in the differential diagnosis, was elicited subsequently in eight patients. Abdominal pain was absent in two and one was comatose on admission. The etiology of AP was hypertriglyceridemia in four, alcohol in two, drug induced in one, and idiopathic in four patients. The hypertriglyceridemia was transient in four patients and resolved once the episode of DKA was corrected. Lipase elevation was noted in 29% and amylase elevation in 21% of all patients with DKA. Similar to increased amylase levels, serum lipase levels were also noted to be high in the absence of CT evidence of AP. DKA may mask coexisting AP, which occurs in at least 10-15% of cases. The pathogenesis of AP in DKA varies, but at least in some transient and profound hyperlipidemia is an identifiable factor. AP is more likely to be associated with a severe episode of DKA with marked acidosis and hyperglycemia. Ranson's prognostic criteria are not applicable to assess the severity of AP in DKA because they overestimate the severity. Severity index based on CT findings appears to better correlate with outcome. Elevation of serum lipase and amylase occur in DKA, and elevation of lipase levels appears to be less specific than amylase levels for the diagnosis of AP in the diagnosis of DKA. Although in this study AP in DKA appeared to be mild, a definite conclusion with regard to the severity should be based only on a much larger number of patients, as only 20% of patients with AP in general have serious disease.

4694 Acute pancreatitis associated with hiv-infection: incidence and predictors of severity.

The increased incidence of acute pancreatitis (AP) in HIV-infected patients is ascribed primarily to complications of medical therapy and opportunistic infections. Recent studies conflict in their assessment of the incidence of severe pancreatitis and the best method to assess the severity of AP in these patients. Our aim was to determine the incidence of severe pancreatitis in HIV- infected patients and to evaluate the accuracy of standard predictors of severity in the course of the disease. Methods: All patients known to be HIV-positive who had a documented episode of AP between 01/89 to 09/99 were identified through a database. AP was defined as an amylase of >200 U/L and 1) a symptom complex consistent with the disease or 2) radiographic evidence of the disease. Parameters required for predicting the severity of pancreatitis (Ranson, Modified Glasgow and APACHE II) plus demographic information, comorbid disease, AIDS-defining illnesses and CD4 counts were obtained. The etiology was determined from medication histories, appropriate investigations and lastly, reported opinion of the attending physician. Episodes of severe pancreatitis were defined by the 1992 Atlanta criteria. Results: Of 2300 patients with documented HIV-disease, 60 cases of AP were identified, of which 39 have beenreviewed. 22 (56%) patients had a history of an AIDS-defining illness (ADI) and a further 9 (23%) patients had CD4 counts of less than 200 cells/μL with no ADI. The etiology of AP was most commonly medication related (43%), followed by idiopathic (23%) and alcohol (19%). Of the 39 episodes of AP, 8 cases (5 deaths) were deemed severe by the Atlanta criteria. Ranson criteria were found to be 50% sensitive and 56% specific overall but 100% sensitive and 33% specific when only those patients with 9 of 11 parameters available were analyzed. The Modified Glasgow score was poor in predicting severity with a sensitivity of 37% and a specificity of 84%. This improved to 75% and 80%, respectively, with exclusion of patients with 5 or less of the 8 criteria required. The APACHE II score had the best overall accuracy with a 75% sensitivity and 83% specificity (88% of the parameters were recorded). There was no correlation between the CD4 count, the duration of HIV-disease or the presence of ADI and the severity of the episode of pancreatitis. Conclusions: In HIV-infected patients presenting with AP: 1) The incidence of severe AP is common, occurring in almost 20% of cases 2) The most accurate grading system to predict the severity of the attack is the APACHE II.

Severe Acute Pancreatitis: Prognostic Factors for Mortality

Several scoring systems (e.g., Ranson criteria) are used to predict the severity of acute pancreatitis. Although these systems also can be used to predict the general risk of death, specific prognostic factors for hospital mortality have not been studied systematically. Researchers from Finland evaluated factors associated with hospital mortality in 270 consecutive patients …

The impact of oral feeding on the severity of acute pancreatitis

Background: In the management of acute pancreatitis, oral feeding is prohibited and either enteral or parenteral feeding is commenced for the patients in an effort to not increase the secretion of the pancreatic enzymes. Purpose: This study was undertaken in an attempt to determine the impact of oral feeding on the severity of acute pancreatitis and to compare this impact with that of parenteral feeding. Materials and methods: Twenty-four female Sprague-Dawley rats were divided into two groups. In both groups, acute pancreatitis was induced by ligation of the main biliopancreatic duct. The rats in group I were fed orally and the rats in group II were fed parenterally. The rats were sacrificed at 48 hours, and blood samples were obtained from the heart upon exposure of the abdominal and thoracic cavities. The pancreas and the left lung were removed for histopathological examination. The levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT), glucose, calcium and blood urea nitrogen, base deficit, partial oxygen pressure, leukocyte count, and hematocrit level among Ranson criteria and the level of amylase were measured. The pancreas and the lung were examined under a light microscope. Results: The levels of LDH, SGOT, and calcium for the rats in group I were significantly higher when compared with the rats in group II ( P <0.05). Similarly, the levels of amylase for the rats in group I were found to be higher when compared with the rats in group II, but the difference was not significant. Inflammatory changes observed in the pancreas were less severe whereas inflammatory changes observed in the lung were more severe for the rats in group I when compared with the rats in group II. Conclusion: The blood levels of the enzymes were adversely affected for the rats fed orally. In contrast, inflammatory changes observed in the pancreas were more severe for the rats fed parenterally. The study suggests that certain hormones released from the duodenum upon stimulation by oral nutrient intake lessens the severity of pancreatitis through protective effects on the pancreas, whereas the elevated levels of the enzymes cause endothelial damage resulting in destruction in distant organs such as the lung.

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) is not necessary in mild gallstone pancreatitis.

The role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis is unclear. Therefore, we designed a study to establish whether ERCP is indicated in these cases. We studied 55 patients who had been admitted with gallstone pancreatitis. All of them had mild pancreatitis (Ranson's criteria <3). ERCP was carried out within 4 days of admission, once the liver function tests and serum amylase had returned to normal levels. ERCP did not demonstrate common bile duct stones in any of the patients. All patients then underwent laparoscopic cholecystectomy during the same admission. Preoperative ERCP is not indicated for patients with mild gallstone pancreatitis.