Journal List > Korean J Gastroenterol > v.54(4) > 1006587

Ryu: Evaluation of Severity in Acute Pancreatitis

Abstract

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.

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Table 1.
Atlanta Criteria for Severity of Acute Pancreatitis
Severity criteria Definition
Organ failure with 1 or more
Shock Systolic blood pressure <90 mmHg
Pulmonary insufficiency PaO2<60 mmHg
Renal failure Serum creatinine level >2 mg/dL after rehydration
Gastrointestinal tract bleeding 500 mL in 24 hours
Local complications
Pancreatic necrosis More than 30% of the parenchyma or more than 3 cm
Pseudocyst Collection of pancreatic juice enclosed by a wall
Abscess Circumscribed collection of pus containing little or no pancreatic necrosis
Ranson score >3
APACHE II score >8
Table 2.
Ranson's Criteria for the Prediction of Severity of Acute Pancreatitis
On admission During initial 48 h
Age>55 years (>70 years) White cell count>16,000/mm3 (18,000/mm3) Decrease in hematocrit by 10% (same) Blood urea nitrogen increases by >5 mg/dL (>2 mg/dL)
Lactate dehydrogenase>350 U/L (>400 U/L) Calcium<8 mg/dL (same)
Aspartate aminotransferase>250 U/L (same) PaO2<60 mmHg (omitted)
Glucose>200 mg/dL (>220 mg/dL) Base deficit>4 mEq/L (>6 mEq/L)
Fluid sequestration>6 L (>4 L)

The criteria for nongallstone (alcoholic) acute pancreatitis are listed first; the changes (if any) in the criteria for gallstone pancreatitis are in parentheses.

Table 3.
Glasgow Severity Scoring System for Acute Pancreatitis
Age>55 years
White cell count>15,000/mm3
PaO2<60 mmHg
Serum lactate dehydrogenase>600 U/L
Serum aspartate aminotransferase>200 U/L
Serum albumin<3.2 g/dL
Serum calcium<8 mg/dL
Serum glucose>180 mg/dL
Serum urea>45 mg/dL
Table 4.
Japanese Severity Score for Acute Pancreatitis
Factor Clinical findings Laboratory measurements
Prognostic factor I Shock Base excess<−3 mEq/L
2 points per positive item Impaired level of consciousness Hematocrit<30% after hydration
Respiratory failure BUN>40 mg/dL
Severe sepsis Serum creatinine>2 mg/dL
Disseminated intravascular coagulation
Prognostic factor II Calcium level<7.5 mg/dL
1 point per positive item Serum glucose>200 mg/dL
Protein<6.0 g/dL
Lactate dehydrogenase>700 IU/L
PaO2<60 mmHg (on room air)
Prothrombin time>15s Platelet count<1×105/mm3
Balthazar score D or E
Prognostic factor III SIRS score>3 (2 points)
Age>70 years (1 point)
Table 5.
BISAP (Bedside Index for Severity in Acute Pancreatitis) Scoring System
BUN>25 mg/dL
Impaired mental status (Glasgow Coma Scale Score<15)
SIRS
SIRS is defined as two or more of the following:
(1) Temperature of <36 or >38oC
(2) Respiratory rate >20 breaths/min or PaCO2<32 mmHg
(3) Pulse>90 beats/min
(4) WBC <4,000 or >12,000 cells/mm3 or >10% immature bands
Age>60 years
Pleural effusion detected on imaging
One point is assigned for each variable within 24 h of presentation and added for a composite score of 0-5.
Table 6.
Balthazar CT Score
Grade CT findings
A Normal
B Focal or diffuse enlargement of the pancreas, including irregularities of contour and inhomogeneous attenuation
C Pancreatic gland abnormalities in grade B plus per pancreatic inflammation
D Grade C plus a single fluid collection
E Grade C plus 2 or more fluid collections and/or the presence of gas in or adjacent to the pancreas
Table 7.
CT Severity Index
CT grade Assigned score Percent necrosis Assigned score
A 0 None 0
B 1 <30 2
C 2 30-50 4
D 3 >50 6
E 4

CT grade based on Balthazar score plus pancreatic necrosis with a maximum score of 10 points.

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