| Research BackgroundAcute pancreatitis, which is an inflammatory disease of the pancreas, is characterized by a discrete episode of abdominal pain and elevated serum amylase and lipase levels. For mild cases, the course of illness takes an average of one week. However, for fatal cases, patients may develop into multiple organ failure and with high rate of mortality. Among the many causes of acute pancreatitis, biliary tract disease and alcoholism are most frequent. The typical symptoms of acute pancreatitis are abdominal pain, nausea, and vomiting. Pain usually develops first and remains constant, without the waxing and waning pattern typical of intestinal or renal colic. The pain is frequently located in the epigastrium with radiation to the mid back region; it typically lasts for hours to days and is not relieved by vomiting. Abdominal findings vary with the severity of the attack, from minimal local tenderness to marked generalized rebound tenderness, guarding, and abdominal distention. Bowel sounds are frequently diminished or absent because of intestinal ileus. In SAP patients, hypotension, tachypnea, tachycardia, and hyperthermia may be noted. Examination of the skin may reveal tender areas of induration and erythema resulting from subcutaneous fat necrosis. In severe necrotizing pancreatitis, large ecchymosis may occasionally appear in the flanks (Grey Turner’s sign) or the umbilical area (Cullen’s sign); these ecchymosis are caused by blood dissecting from the retroperitoneally located pancreas along the fascial planes.The diagnosis of AP is based on clinical manifestations and supported by an elevation in serum amylase or lipase levels and imageology examination. AP is diagnosed in the presence of one of the following conditions:(1) consistent with the AP in patients with abdominal pain; (2) laboratory examinations showed serum amylase and (or) lipase levels were significantly increased (more than upper limit of normal value three times); (3) imaging examinations showed radiographic changes consistent with acute pancreatitis.Acute pancreatitis is a relatively common and important gastroenterological disease with complicated clinical processes. In 2009, approximately 274,119 AP patients were admitted to hospitals for treatment in the United States, and the total hospitalization expenses were nearly $2.6 billion. Numerous previous studies have indicated that mild acute pancreatitis (MAP) accounted for the majority of cases and that without other organ dysfunction, the patients recovered relatively quickly and without local or systemic complications. However, when the patient is diagnosed with severe acute pancreatitis (SAP), the situation changes. Yadav J et al. showed a mortality rate of 28.57% for SAP patients in an Indian setting,and in a single-center pilot study in China, Wu Dong et al. reported that the mortality rate for SAP patients was as high as 38%, and the rate of intensive care unit (ICU) admission was 66.7%. In moderately severe acute pancreatitis (MSAP) patients, the medical expenses and hospitalization days were not significantly different from those of SAP patients, but the mortality rate was relatively lower. Therefore, accurate classification is critical and necessary because various degrees of AP are related to differences in the severity of patients’ conditions and prognosis. Over the years, many researchers from different countries have attempted to develop an accurate and practical classification method for AP that can be applied widely in the clinical field. The 1992 Atlanta classification, which defined AP in terms of MAP and SAP, is the most widely used system. In the 2013 Atlanta classification, the criteria for MAP were not changed, but SAP was further categorized as "moderately severe" or "severe" . We compared SAP and MSAP in terms of system scores, clinical characteristics, and prognosis.Numerous studies have indicated that organ failure is the main cause of death in patients with SAP. One retrospective study of AP patients between 1992 and 2001 demonstrated that compared with patients with multiple organ failure (MOF), patients with single organ failure (SOF) had shorter hospital stays, a reduced need for ICU care, shorter ICU stays, and lower mortality. In our research, the patients in the SAP group were further stratified into two subgroups according to the number of persistent (≥ 48 h) organ failures (OF). We attempted to explore the clinical value of the persistent MOF criterion in the latest Atlanta classification and to search for a more detailed and effective classification method.When assessing a patient’s condition and the risk of developing SAP at an early stage, prognostic scoring systems play a vital role in the diagnosis and treatment processes. The Ranson, the Acute Physiology and Chronic Health Examination II (APACHE II), the Bedside Index of Severity in Acute Pancreatitis (BISAP), the CT severity index (CTSI), and the modified CT severity index (MCTSI) scores are commonly used in clinical settings. The APACHE II scoring system is based on 14 indicators, including 12 physiological measurements, the patient’s age, a chronic health score.It considers the impact of both age and chronic health and is not affected by factors related to treatment and hospitalization time. The Ranson score was proposed in 1974 and includes 11 clinical and laboratory parameters. The BISAP scoring system was proposed in 2008, it was based on a large sample (36,428) collected from the Prospective Institute and yields a score between 0 and 5. As an adaptation of the CTSI score, the MCTSI includes pancreatic lesions as a new observation index. Similar to the CTSI, the MCTSI score is calculated according to CECT findings. Our study evaluated the value of these scoring systems for predicting SAP, persistent multi-organ failure, complications, and death in the latest Atlanta Classification.Objective1. To analyze the difference of clinical characteristics and prognosis between patients with severe accurate pancreatitis (SAP) and moderately severe acute pancreatitis (MSAP) confirmed according to the latest Atlanta classification.2. In addition, we attended to seek a means of further classifying of SAP based on the number of persistent (≥ 48h) organ failure and analyze the difference of clinical characteristics and prognosis between MOF subgroup and SOF subgroup.3. Evaluated the previous scoring systems such as Ranson, APACHE Ⅱ, BISAP and MCTSI, and attempted to explore their potential predictive value.MethodsThe medical records of 1109 patients admitted with a primary diagnosis of acute pancreatistis to the Nangfang Hospital between February 2011 and September 2015 were reviewed. According to the 1992 Atlanta classification,337 cases were diagnosed with SAP. Among the traditional SAP patients,263 cases were in early phase of the disease, which usually lasts for the first week. Finally, a total of 207 patients with complete clinical data were included in the study. These patients were re-classified into SAP and MSAP based on the latest Atlanta Classification. All of the patients were diagnosed with MSAP or SAP according to the latest Atlanta Classification. MSAP is diagnosed in the presence of one of the following conditions:(1) transient OF (< 48 h) or (2) systemic or local complications. The diagnostic criterion for SAP is persistent OF (≥48 h). The diagnostic criterion for OF is a modified Marshall score of more than 2 points. According to the number of persistent OF, the SAP patients were further stratified into a SOF subgroup (persistent OFs=1) and a MOF subgroup (persistent OFs≥2). The demographic and clinical characteristics and prognosis of the patients in the MSAP group, the SAP group, the MOF subgroup and the SOF subgroup were compared. Using the criteria of these scoring systems, the scores for each patient were calculated, and the value of these scores for predicting the duration of hospitalization, hospitalization expenses, death and other clinical outcomes was analyzed. The APACHE Ⅱ and BISAP scores were calculated within 24 hours after admission, and the Ranson score was calculated using the data from the first 48 hours after admission. The MCTSI was calculated for patients who underwent contrast-enhanced computed tomography (CECT) within one week of admission, and all CECT scans were reviewed by radiologists specializing in abdominal imaging. And we used the area under the receiver-operating curve (AUC) to assess the predictive value of these scoring systems.Results1. Patient demographics:This retrospective study enrolled 207 traditional SAP patients, including 131 patients with confirmed MSAP and 76 with SAP according to the latest Atlanta Classification. Among the 76 SAP patients,52 were in the SOF subgroup, and 24 were in the MOF subgroup. For 45 patients, this was not their first attack of AP. Regarding etiology, there were 104 cases of biliary pancreatitis (50.24%),35 cases of hyperlipidemic pancreatitis (16.91%),18 cases of alcoholic pancreatitis (8.69%),44 cases of idiopathic pancreatitis (21.26%),5 cases of post-ERCP pancreatitis (2.42%), and 1 case resulting from trauma (0.48%) among the 207 total patients. The morbidity of biliary pancreatitis is the highest, accounting for more than half of the enrolled patients; this indicates that it is still the main cause of AP in Chinese patients. The average age of the patients was 50.73 ± 16.26 years, and males were in the majority at 62.80%. In the SAP patients, the average number of days of hospitalization or fasting was notably longer and the medical expenses were much higher than those of the MSAP group (P< 0.001 for each endpoint). There were no significant differences between the MSAP group and the SAP group in leading cause, the distribution of age and gender(P> 0.05 for each endpoint). There was no significant difference between the SOF subgroup and the MOF subgroup in the leading cause of AP or the distribution of age and gender (P> 0.05 for each endpoint).2. Comparison of the incidence of organ failure:In the 207 patients, the incidence of organ failure was 57.97%(120/207); the incidence of respiratory failure was 52.17%(108/207); the incidence of renal failure was 17.39%(36/207); and the incidence of circulation failure was 10.14%(21/207). In the MSAP group, the incidence of organ failure was 33.59%(44/131); the incidence of respiratory failure was 27.48%(36/131); the incidence of renal failure was 3.82%(5/131); and the incidence of cardiovascular failure was 3.05%(4/131). In the MSAP group, organ failure persisted less than 48 hours. In the SAP group, the patients had different extents of organ failure:the incidence of respiratory failure was 94.74% (72/76), followed by renal failure in 40.79%(31/76) and circulatory failure in 22.37%(17/76). In the SAP group, the incidence of respiratory failure, renal failure and cardiovascular failure and the overall incidence of organ failure were higher than in the MSAP group (P< 0.05).3. Clinical outcomes and prognosis of the patients in each group:The SAP group had significantly higher values for mortality, ICU admission, trachea cannula use, vasoactive drug use, dialysis, blood transfusion, and endoscopic jejunal feeding tube placement compared with the MSAP group (P< 0.01 for each endpoint). There was no statistically significant difference in the proportion of surgery (P> 0.05) between the two groups. Compared with the patients in the SOF subgroup, the patients in the MOF subgroup had a greater need for ICU care, more days in the ICU, and increased mortality (P< 0.01 for each endpoint). In contrast, a much higher proportion of the patients in the MOF subgroup required dialysis, trachea cannulas, blood transfusions, endoscopic jejunal feeding tube placement, and vasoactive drugs (P< 0.01 for each endpoint). However, there was no difference in hospitalization days, fasting days, medical costs, and the need for interventions between the two subgroups (P> 0.05 for each endpoint).4. Comparison of different scoring systems:The Ranson, APACHE Ⅱ, BISAP, MCTSI and CTSI scores were all significantly higher in the SAP group than in the MSAP group (P< 0.01 for each endpoint). Among the subgroups, the MOF subgroup had higher Ranson, APACHE Ⅱ, and BISAP scores compared with the SOF subgroup (P< 0.05 for each endpoint), but there was no significant difference in the MCTSI and CTSI scores (P> 0.05 for each endpoint). These scores were also higher in the SOF subgroup (P< 0.01 for each endpoint) compared with the MSAP group.5. Comparison of the predictive value of different scoring systems:For the prediction of SAP, the ROC curve of the APACHE Ⅱ scores yielded the highest area under the curve (AUC) value of 0.87 (95%CI 0.82-0.92), followed by the ROC curve of the Ranson score with an AUC value of 0.86 (95%CI 0.81-0.91). For the prediction of persistent MOF, APACHE Ⅱ had the highest AUC of 0.91 (95%CI 0.87-0.95), followed by the BISAP with and AUC of 0.86 (95%CI 0.80-0.90). Regarding local complications, the MCTSI had the highest AUC of 0.95 (95%CI 0.91-0.97); for systemic complications, the BISAP achieved the highest AUC of 0.83 (95%CI 0.77-0.88). Finally, as a predictor of death, APACHE Ⅱ had the highest AUC of 0.91 (95%CI 0.86-0.95), followed by the Ranson score an AUC of 0.85 (95%CI 0.79-0.89).CONCLUSION1. The division of the severity of acute pancreatitis was more meticulous, and the definition of severe acute pancreatitis was clearer in the latest Atlanta Classification. There are significant differences in the consumption of medical resource, condition, and prognosis between MSAP and SAP group.2. If SAP patients accompanied with persistent multiple organ failure, the treatment process will be more complicated, and the prognosis will be worse. Our research indicated that the mortality rate of the patients in the MOF subgroup was higher, and the patients were more likely to need intubation, dialysis, vasoactive drugs, and blood transfusions.3. These scoring systems still have high value of application in clinical under the latest Atlanta classification. The dynamic monitoring of clinical indicators and any abnormal changes in scores has important significance in the clinical treatment process. |
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