BILIARY TRACT: CLINICAL REVIEW
Factors Inﬂuencing Mortality in Acute Pancreatitis
Can We Alter Them?
C. S. Pitchumoni, MD, FRCP(C), FACP, MACG, MPH,* Nayan M. Patel, DO, MPH,† and Prasanna Shah, MD‡
Abstract: Severe acture pancreatitis (SAP), a multisystem disease,
is characterized by multiple organ system failure and additionally by local pancreaticcomplications such as necrosis, abscess, or pseudocyst. The rate of mortality in SAP, which is about 20% of all cases of acute pancreatitis (AP), may be as high as 25%, as in infected pancreatic necrosis. The factors that inﬂuence mortality in different degrees are various. Etiology for the episode, age, sex, race, ethnicity, genetic makeup, severity on admission, and the extent and nature of pancreaticnecrosis (sterile vs. infected) inﬂuence the mortality. Other factors include treatment modalities such as administration of prophylactic antibiotics, the mode of feeding (TPN vs. enteral), ERCP with sphincterotomy, and surgery in selected cases. Epidemiological studies indicate that the incidence of AP is increasing along with an increase in obesity, a bad prognostic factor. Many studies haveindicated a worse prognosis in idiopathic AP compared to pancreatitis induced by alcoholism or biliary stone. The risk for SAP after ERCP is the subject of extensive study. AP after trauma, organ transplant, or coronary artery bypass surgery is rare but may be serious. Since Ranson reported early prognostic criteria, a number of attempts have been made to simplify or add new clinical or laboratorystudies in the early assessment of severity. Obesity, hemoconcentration on admission, presence of pleural effusion, increased fasting blood sugar, as well as creatinine, elevated CRP in serum, and urinary trypsinogen levels are some of the well-documented factors in the literature. The role of appropriate prophylactic antibiotic therapy although still is highly controversial, in properly chosen casesappears to be beneﬁcial and well accepted in clinical practice. Early enteral nutrition has gained much support and jejunal feeding bypassing the pancreatic stimulatory effect of it in the duodenum is desirable in selected cases. The limited role for endoscopic sphincterotomy in patients with demonstrated dilated CBD with impacted stone and evidence of impending cholangitis is well documented.Surgery in AP other than for removal of the gallbladder is often limited to infected pancreatic necrosis, pseudocysts, and pancreatic abscess and in some cases of traumatic pancreatitis with a ruptured duct system. The progress in the understanding of the role of cytokines will over us opportunities to use immunomodulatory therapies to improve the outcome in SAP. Key Words: Acute pancreatitis,pancreatic necrosis, pseudocyst, prophylactic antibiotic therapy in pancreatitis, mortality in acute pancreatitis, nutrition in pancreatitis, ERCP, TPN, enteral nutrition (J Clin Gastroenterol 2005;39:798–814)
FACTORS INFLUENCING MORTALITY IN ACUTE PANCREATITIS: CAN WE ALTER THEM?
Acute pancreatitis (AP) is an acute inﬂammatory disease of the pancreas that in its severe form becomes a multisystemdisease.1 According to the Atlanta system of classiﬁcation, severe AP (SAP) is associated with multiple organ system failure, and additionally may include local complications such as necrosis, abscess, or pseudocyst.2 Interstitial or edematous pancreatitis is mild and characterized by lack of pancreatic glandular necrosis and is associated with an uneventful recovery.2 (See Table 1 for deﬁnitionsbased on Atlanta classiﬁcation of Acute Pancreatitis). Of the nearly 210,000 patients admitted to hospitals each year with AP, about 20% have SAP.3 Mild AP is associated with minimal organ dysfunction and an uneventful recovery and lacks the described features of SAP. SAP progresses in two phases. During the ﬁrst 7 to 14 days or even sometimes before the patient experiences the ﬁrst episode of...