| Acute pancreatitis?AP?,an acute illness,refers to pancreatic enzyme activation caused by various causes,followed by a local inflammation of the pancreas,with or without other organ function changes of the body.In China,it has become a common disease in hospital for patients with digestive diseases.Currently,the annual incidence rate of AP worldwide is about?13-45?/100,000[1].Uncommon causes includehyperlipidemia,hypercalcemia,andendoscopicretrograde cholangiopancreatography?ERCP?.About 20%of them have unknown etiology,known as“idiopathic acute pancreatitis”?IAP?[2].Acute pancreatitis has a wide range of causes,including gallstone disease,smoking and heavy drinking.In China,over50%of AP is caused by biliary tract diseases,while in developed countries,the common causes are gallstones and alcohol[3].In addition to traditional reasons,the effects of common factors such as the use of certain drugs,obesity and genetic susceptibility are considered to be increasingly important[4].With the input of a large amount of clinical research,more and more is being learned about AP,and the management of this disease is becoming more and more standardized.The mortality rate of AP has decreased significantly,but there are still20%-30%of patients with AP progressed into severe acute pancreatitis?SAP?,with a mortality rate ranging from 2%to 10%.A recent global disease burden report shows that the age-standardized mortality rate of pancreatitis in China has remained unchanged since 1990[4].Most patients with AP follow a mild,self-limiting clinical course.However,20%-30%of patients with AP developed into SAP,which,associated with organ failure,may be life-threatening.Understanding the occurrence and mechanism of multiple organ damage in AP is of great significance to the development of the disease and organ support therapy.A variety of severity scoring systems have been designed to help clinicians classify AP patients and predict their prognosis due to their diverse manifestations and unknown pathophysiology.The currently widely used scores include:Acute Physiology and Chronic Health Status Score?APACHE2?,RANSON Score,Modified Marshall Score,SOFA Score,BISAP Score,SIRS Score,Modified Early Warning Score,etc.Although such systems have been widely used in acute and severe diseases,there are still many defects in the evaluation of AP.Among them,APACHE2 Score,RANSON Score,Modified Marshall Score,and SOFA Score cannot make immediate evaluation,and they takes 24 hours or even longer to evaluate,with many items.Especially,APACHE2 Score,RANSON Score,and Modified Marshall Score need the results of blood gas analysis,which increases the pain and unnecessary financial burden to non-ICU patients.,and such systems are more suitable for critically ill patients in the ICU.BISAP Score needs to be combined with imaging results and is subjective.MEWS has too few items and has low specificity and sensitivity to predict the severity and prognosis of AP.There are a lot of serum markers such as C-reactive protein?CRP?,Procalcitonin?PCT?,interleukin 6?IL-6?and interleukin 8?IL-8?,as well as those which are studied in laboratories but difficult to be popularized clinically,have been proposed to independently predict the prognosis or severity of AP.But they are expensive,not easy to obtain,and unable to adequately predict the prognosis or severity of AP.Many people have begun to pay attention to the laboratory tests that are more popular and have not been valued in the past,such as red blood cell distribution width,neutrophil/lymphocyte ratio,albumin,urea nitrogen,etc[5-7].Some predictive models for evaluating the prognosis of AP have been established,but these prediction models still more or less flawed and are not suitable for popularization.To sum up,multiple organ failure caused by AP has been widely concerned,but its mechanism needs further study to provide evidence for better kidney protection in therapy.We will also establish a convenient,practical and accurate model for the prognosis of AP.The study will be divided into three parts as below.1.Clinical characteristics analysis of APMethodsThe study is a retrospective study,focusing on patients with symptoms such as abdominal pain diagnosed as AP at the First Affiliated Hospital of Zheng Zhou University from July 2011 to July 2018.To obtain and record the general condition and epidemiological characteristics of the patients,the author investigated the degree and sequence of the functional damage of each organ at the time of admission and after admission,and the correlation between the damage of each organ and the prognosis of the patients.According to the prognosis of acute pancreatitis,patients were divided into two groups,which survival group refers to healed and improved patients,and death group refers to in-hospital death and death from acute pancreatitis after discharge.The differences in dysfunction of organs in the survival and death groups were compared.Results1.Of the 3919 patients,101 died and the mortality rate was 2.58%.2.A total of 1541 cases of organ dysfunction occurred,accounting for 39.3%of all AP patients,of which 827 cases occurred with 2 or more organ dysfunction,accounting for 21.1%of all AP patients.3.621 cases of liver dysfunction,578 cases of survival group,43 cases of death group,the mortality rate was 6.9%;583 cases of gastrointestinal dysfunction,546cases of survival group,37 cases of death group,the mortality rate was 6.3%;397cases of pulmonary dysfunction,330 cases in the survival group,67 cases in the death group,the mortality rate was 16.9%;353 cases of blood system dysfunction,314 cases of survival group,39 cases of death group,the mortality rate was 11%;304cases of renal dysfunction,250 cases of survival group,54 cases of death group,the mortality rate was 17.8%;277 cases of cardiac insufficiency,226 cases of survival group,51 cases of death group,the mortality rate was 18.4%;79 cases of brain dysfunction,55 cases of survival group,24 of death group,the mortality rate is 30.4%.4.Liver,lung,blood,kidney,heart,brain dysfunction and death were statistically significant?P<0.001?,while gastrointestinal dysfunction was not associated with death?P=0.34?.5.Among 101 AP patients who died,Death from MODS in 34 cases?33.66%?;Death from septic shock in 17 cases?16.83%?;Death from septic shock combined with MODS in 17 patients?16.83%?;Death from abdominal hemorrhage in 6 cases?5.94%?;Death from abdominal hemorrhage complicated with septic shock and MODS in 6 cases?5.94%?;Deaths from acute coronary syndrome in 5 cases?4.95%?;Liver failure,gastrointestinal bleeding,respiratory failure,cerebral hemorrhage secondary to coagulation system dysfunction and death caused by shock were all 3cases?2.97%?.Respiratory and cardiac arrest caused death in 1 patient?0.99%?.Conclusion1.AP can cause liver,gastrointestinal,lung,kidney,heart,brain and other multiple organ damage,the incidence of organ dysfunction in the death group is significantly higher than the survival group;2.The organ most easily involved in AP is liver,gastrointestinal,lung,blood,kidney,heart,brain;3.In addition to gastrointestinal dysfunction,liver,lung,blood,kidney,heart,brain dysfunction are significantly associated with prognosis.4.The leading cause of death in AP patients was MODS,followed by septic shock and bleeding,and the other causes were circulatory failure,liver failure,respiratory failure and coagulation disorder.2.Early predictive indicators of poor prognosis in acute pancreatitis.MethodsThe general conditions of subjects in the first part,such as chronic history,etiology,vital signs on admission and laboratory results within 24 hours of admission,are studied in depth.The statistical indicators of the death group and the survival group are analyzed in depth to find out the indicators with statistical significance.Results1.Compared the death group with the survival group,the factors correlated with the prognosis in the univariate analysis are:age,body temperature?T?,respiratory rate?R?,heart rate?HR?,blood pressure?BP?,white blood cell count?WBC?,hemoglobin?Hb?,platelet count?PLT?,neutrophil percentage?Neut%?,lymphocytes percentage?Lymph%?,neutrophil count?Neut#?,platelet distribution width?PDW?,mean platelet volume?MPV?,nucleated red blood cell percentage?NRBC%?,neutrophil lymphocyte ratio?NLR?,lymphocyte mononuclear cell ratio?LMR?,amylase?AMY?,lipase?LIP?,albumin?ALB?,alanine transaminase?ALT?,aspartate aminotransferase?AST?,total bilirubin?TBIL?,direct bilirubin?DBIL?,Indirect bilirubin?IBIL?,cholinesterase?CHE?,Urea,creatinine?CREA?,uric acid?UA?,glucose?GLU?,blood sodium?Na?,blood potassium?K?,blood chlorine?CL?,blood calcium?CA?,blood phosphorus?P?,blood magnesium?MG?,prothrombin time?PT?,activated partial thromboplastin time?APTT?,International standardization ratio?INR?,clotting time?TT?,diabetes,coronary heart disease,and chronic bronchitis.After logistic regression analysis,the predictive values are heart rate,PLT,and hemoglobin?Hb?.2.After logistic analysis,the predictive value factors were heart rate?P<0.001OR=1.044?,platelet count?P<0.001 OR=0.974?,and hemoglobin?P<0.001OR=0.991?.ConclusionHeart rate,PLT and Hb are statistically significant for prognosis within 24 hours of admission.3.Establishment of a prognostic model of AP,compared with the existing scoring system.MethodsThe indicators with statistical differences obtained from study 2 are analyzed by ROC curve to calculate the cut off value,specificity,sensitivity,positive predictive value,negative predictive value,diagnostic accuracy,Jordan index and area under the curve?AUC?of each indicator.The first N digit index of the maximum area under the curve is obtained,and then based on these indexes,the mathematical equation is obtained.Compared the equations with the new model and the existing scoring system,a quick,simple and economical method for prognosis of acute pancreatitis is found.Results1.The resulting equation is:ln[P/?1-P?]=0.044?HR?-0.026?Hb?-0.01?PLT?+0.001?ALT?-3.372;In the new model:the area under ROC curve?AUC?is 0.923,the cut off value is-3.5865,the sensitivity is 94.7%,and the specificity is 67.5%.2.Predicting the prognosis of AP using MEWS score and SIRS score,MEWS score:AUC:0.714 Cut-off value:4.5 Sensitivity:0.684 Specificity:0.839;SIRS score:AUC:0.853 Cut-off value:3.5 Sensitivity:0.889 Specificity:0.671.3.Compare the MEWS score and SIRS score with the ROC curve of the new model?Z test?.The MEWS score is equal to 2.57 and the bilateral P value is 0.01.The SIRS score is equal to the new model.0.74,bilateral P value of 0.46.Conclusion1.The new model is:ln[P/?1-P?]=0.044?HR?-0.026?Hb?-0.01?PLT?+0.001?ALT?-3.372;2.The new model predictive significance is higher than the MEWS score,and there is no statistically significant difference compared with the SIRS score.3.The establishment of the new predictive model can predict the prognosis of AP patients more quickly and accurately.It is of great value to improve the prognosis of critically ill patients and to give more attention and active treatment to the population.It is in line with the current individualization of clinical diagnosis and treatment.The requirements for treatment are easily implemented in medical centers at all levels. |
PDF Full Text Request