BANK et al. In this study, we compared two different strategies in the approach and management of these patients and observed different results that could exemplify what has happened in other centers. Nevertheless, the Atlanta criteria have been questioned in the last years. BUTER et al. This observation has been confirmed in a larger group of patients recruited across the UK Therefore, APACHE II may not represent an accurate method of evaluation of severity of these patients, if it would be considered only its value on admission.
Furthermore, a 45 year-old patient, for example, has 2 points higher in APACHE II score than a 44 year-old patient, making the age criterion a controversial point. It is irrefutable that despite the similarity of the groups in this study, group A had a retrospective evaluation that has known limitations, and probably some patients that were included as severe in group B, would not be considered severe in group A giving a stricter sense of severity in group A. To clarify this doubt and to answer some methodological issues regarding the comparison of two groups with different approaches, we applied, in addition, the same criteria of severity employed in group A in patients of group B, demonstrated in Table 5.
It was observed a reduction from 47 to 30 in patients considered severe in group B, indicating a stricter criteria of severity used previously to Atlanta classification. This occurred because signs of organic failure and local complications, and not Atlanta criteria were utilized in group A, and in Table 5 also in group B. Interestingly very similar results were observed in Table 5 when compared to Table 1 , despite distinct criteria of severity used in group B, especially regarding the reduction in need of operation and mortality in group B when compared with group A in both Tables.
Moreover, in Table 1 we observed more fluid collections in group A, although without statistical significance This difference regarding fluid collections between groups was over in Table 5. Considering Table 1 to a more detailed analysis, curiously, the age was different between groups. Patients in group B were 8. This difference could be explained by a higher number of patients with alcoholic etiology in group A and more patients with biliary etiology in group B.
Regarding gender, these results are consistent with the literature 1, Although gallbladder disease is more frequent in women, men develop AP more often. One of the reasons is the high incidence of alcoholic pancreatitis in men If we analyze all the patients with SAP in both groups, 47 With regards to etiology, the main cause of AP in group A was alcoholic and in group B was biliary.
[Full text] Acute pancreatitis: current perspectives on diagnosis and management | JIR
Some authors relate the etiology of AP to a worse prognosis. The diagnosis of AP in these alcoholic patients can be difficult due to a frequent normal serum amylase on admission. The key to the diagnosis of AP in those patients is the serum lipase, which is more specific than amylase. Despite a normal amylase, lipase is often elevated in patients with alcoholic etiology and confirms the diagnosis. CT scan may be useful in these situations Many authors have tried to establish predictors of mortality in SAP and thus, to obtain an improvement in the results. Systemic complications such as renal and pulmonary failure were related to mortality.
The high mean age of 69 years old and the high number of patients with necrosis In another paper, KONG et al. They concluded that fatal outcome was predicted by respiratory, cardiovascular and renal failures. Hence, it is a consensus that the development of systemic complications in a patient with necrosis can lead to a worst prognosis 11, Our number of patients is still small to consider an analysis about predictors of mortality, although based on these results and in those described above, it is easy to mention that a more careful approach to patients with SAP, and in particular those with necrosis, results in lower morbidity and mortality.
This approach includes appropriate fluid administration, intensive care unit, use of antibiotics and nutritional support, with emphasis to enteral nutrition 2, 22, This is the starting point that motivated our new protocol. The reduction of surgical treatment need or its postponement plays a critical role in the improvement of the prognosis of these patients. The early use of antibiotics in 32 Furthermore, in the same study, the mean time to open the protocol was Based on these data, it is reasonable to suppose that a group of patients had benefited from receiving early antibiotics.
This opinion is the same of other authors 6.
Management Guidelines for Acute Pancreatitis
Moreover, most of recent guidelines and reviews about the treatment of AP recommend the use of antibiotics in necrotizing AP 4, 9, 10, 13, 22, 25, 26, 32, 36, Two new studies regarding the use of antibiotics in AP were published in 16, 28 , but with controversial results and some methodological problems. The use of enteral nutrition when necessary is another important factor that may play a role in the improvement of patients in group B. The parenteral route is a potential focus of systemic infection in these patients.
The association of antibiotics and enteral nutrition may justify the reduction of pancreatic sepsis and consequently the need of operation. However, despite the use of antibiotics, enteral nutrition and improvement in the ICU treatment, another important factor in our opinion that makes a difference in the treatment of these patients is the creation of a "pancreatitis team". In conclusion, a specific approach and management can improve the results of patients with AP.
Due to a more careful evaluation by an uniform team, patients with SAP can be identified earlier, allowing the specific care to be applied in time. Incidence, management and recurrence rate of acute pancreatitis.
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12222 WSES guidelines for the management of severe acute pancreatitis
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