Predicting the Severity of Pancreatitis

Educational Objectives

The goal of this program is to improve the management of pancreatitis. After hearing and assimilating this program, the clinician will be better able to use diagnostic criteria scores to predict the severity of acute pancreatitis.

Summary

Background: obesity increasingly seen as risk factor; most pancreatitis interstitial, edematous, and resolves with no sequelae; however, small proportion become necrotic (necrosis of gland and peripancreatic area); mortality <1% for all acute pancreatitis (largely alcoholic); infection significantly increases mortality

Etiology: gallstones; toxins; alcohol; drugs; trauma (including iatrogenic due to endoscopic retrograde cholangiopancreatography [ERCP]); idiopathic

Revised Atlanta classification: early-phase disease — systemic inflammatory response syndrome (SIRS) leads to complications and outcomes; late-phase disease — after 2 wk, complications due to infection, sepsis, and obesity (body mass index [BMI] >30)

Diagnostic criteria scores: Ranson criteria; Glasgow criteria; APACHE II; SIRS criteria; PANC 3; Pancreatitis Outcome Prediction (POP) score; Bedside Index for Severity in Acute Pancreatitis (BISAP); Japanese Severity Score (JSS); Harmless Acute Pancreatitis score; GI failure score; CT severity index (usually incorporated into other scores); serum urea nitrogen (BUN), CRP, trypsinogen activation peptide, creatinine, and hematocrit

Scoring difficulties: few comparative studies available; etiologies vary; some scores observe 1 point in time, while others continuous (eg, Ranson criteria measured at admission and 48 hr, APACHE score utilized with any change in variables); scores may not incorporate pathophysiology

Evaluation: Atlanta Criteria — consensus statement; persistence of organ failure now known to predict poor outcomes; however, response of blood pressure, creatinine, or other factors within first 48 hr predicts better outcomes; Ranson criteria — higher score predicts lower survival; Balthazar CT classification — determines whether necrosis present (indicates severity); CT — retrospective studies show intravenous contrast possibly detrimental; use when diagnosis unclear, patient not improving after 36 to 72 hr of treatment, or to determine etiology or complication; GI failure score — based on belief that failure of gut barrier leads to multiorgan failure; however, not superior to APACHE II score or Sequential Organ Failure Assessment score; comparison study — admission assessment of patients with acute pancreatitis showed sensitivity of scores ranged from 56% (for BUN) to 85% (for Glasgow score); positive and negative predictive values good for all scores; area under the curve (AUC) best for Glasgow score; 48-hr assessment showed poor positive predictive value but good negative predictive values on all scores; AUC best for JSS; significance — patients present ≈12 hr after onset of symptoms; cytokine production (cause of injury) begins at onset of pain; thus, most patients present after anticytokinetherapy possible

Treatment: most patients do not develop severe disease; patients who do not qualify for scoring unlikely to develop severe disease; however, patients who cross threshold of scoring (on any testing) should be monitored in step-down unit in light of possibility of rapid deterioration

Summary: scoring has likely reached maximum efficiency; all scores similar and have high negative predictive value; Ranson criteria remain relevant persistent organ failure most effective determinant of severity

Readings

Suggested Reading

Banks PA et al: Classification of acute pancreatitis — 2012: revision of the Atlanta classification and definitions by international consensus. Gut 62:102, 2013; Balthazar EJ: Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 223:603, 2002; Boller AM, Nelson H: Colon and rectal cancer: laparoscopic or open? Clin Cancer Res 13: 6894s, 2007; Bradley EL: A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 Through 13, 1992. Arch Surg 128:586, 1993; Kalady MF et al: Risk of colorectal adenoma and carcinoma after colectomy for colorectal cancer in patients meeting Amsterdam criteria. Ann Surg 252:507, 2010; Larson DW et al: Surgeon volume does not predict outcome in the setting of technical credentialing: results from a randomized trial in colon cancer. Ann Surg 248:746, 2008; Luglio G, Nelson H: Laparoscopy for colon cancer: state of the art. Surg Oncol Clin N Am 19:777, 2010; Mounzer R et al: Comparison of existing clinical scoring system to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology 142:1476, 2012; Parry S et al: Metachronous colorectal cancer risk for mismatch repair gene mutation carriers: the advantage of more extensive colon surgery. Gut 60:950, 2011; Parsons HM et al: Association between lymph node evaluation for colon cancer and node positivity over the past 20 years. JAMA 308:1089, 2011; Smith AJ et al: Guideline for optimization of colorectal cancer surgery and pathology. J Surg Oncol 101:5, 2010; van Sanvoort HC et al: A step-up approach or open necrosectomy for necrotizing pancreatitis. N Eng J Med 362:1491, 2010; van Sanvoort HC et al: A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141:1254, 2011; West NP et al: Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857, 2008.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Lara was recorded at the 12th Annual Surgery of the Foregut Symposium, held February 17-20, 2013, in Coral Gables, FL, and sponsored by Cleveland Clinic Florida. To view information on programs presented by the Cleveland Clinic Florida, please visit ClevelandClinicFloridaCME.org. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS601702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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