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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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Related Articles

Ann Surg ; Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. Nutrition support in acute pancreatitis: a systematic review of the literature. UK guidelines for the management of acute pancreatitis. Gut ; 54 Suppl 3: iii1-iii9. Tse F, Yuan Y.

Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol ; It contains 55 statements on diagnosis, management in the ICU, surgical and operative management, open abdomen, and antibiotic treatment. For some of the statements such as severity grading, imaging, use of prophylactic antibiotics and most aspect of the management in the ICU, the evidence is strong.

For others, such as laboratory diagnostics and surgical strategies, for example, the evidence is quite weak requiring further studies. With accumulating knowledge, the statements need to be regularly updated. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Classification of acute pancreatitis— revision of the Atlanta classification and definitions by international consensus.

Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Position paper: timely interventions in severe acute pancreatitis are crucial for survival. World J Emerg Surg. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force. Mechanisms and management of acute pancreatitis. Gastroenterol Res Pract. Practice guidelines in acute pancreatitis.

Am J Gastroenterol. Acute pancreatitis: recent advances through randomised trials. The Atlanta classification of acute pancreatitis revisited. Br J Surg. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis.

Johnson CD. Organ failure and acute pancreatitis. Prediction and management of severe acute pancreatitis. New York: Springer; ISBN Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. Yadav D. Acute pancreatitis: too many classifications-what is a clinician or researcher to do? Clin Gastroenterol Hepatol. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis.

Br J Surg ;— Revised Atlanta and determinant-based classification: application in a prospective cohort of acute pancreatitis patients. Association between severity and the determinant-based classification, Atlanta and Atlanta , in acute pancreatitis: a clinical retrospective study. Medicine Baltimore. Clinical relevance of the revised Atlanta classification focusing on severity stratification system. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis.

Gastroenterol Hepatol. Working Party of the British Society of Gastroenterology. UK guidelines for the management of acute pancreatitis. Japanese guidelines for the management of acute pancreatitis: Japanese guidelines J Hepatobiliary Pancreat Sci. American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis.

The use of imaging in acute pancreatitis in United Kingdom hospitals: findings from a national quality of care study. Br J Radiol. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Acute pancreatitis: value of CT in establishing prognosis. Necrotizing pancreatitis: diagnosis, imaging, and intervention. Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much? J Gastrointestinal Surg.

Is magnetic resonance cholangiopancreatography the new gold standard in biliary imaging? Guidelines for the management of acute pancreatitis. J Gastroenterol Hepatol. Laboratory diagnosis of acute pancreatitis: in search of the holy grail. Crit Rev Clin Lab Sci. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis.

Cochrane Database Syst Rev. Rapid urinary trypsinogen-2 test in the early diagnosis of acute pancreatitis: a meta-analysis. Clin Biochem. Serum inter-cellular adhesion molecule 1 is an early marker of diagnosis and prediction of severe acute pancreatitis.

References

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GENERAL CONSIDERATIONS

Prognostic models for predicting the severity and mortality in people with acute pancreatitis. Cochrane Database Syst Rev ;, Issue 5. Wu BU. Prognosis in acute pancreatitis. The pancreatitis outcome prediction POP score: a new prognostic index for patients with severe acute pancreatitis. Crit Care Med. Dig Dis Sci. Comparison of scoring systems in predicting the severity of acute pancreatitis. The early prediction of mortality in acute pancreatitis: a large population-based study. Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure.

Hepatobiliary Pancreat Dis Int. Overweight is an additional prognostic factor in acute pancreatitis: a meta-analysis. Predicting and evaluation the severity in acute pancreatitis using a new modeling built on body mass index and intra-abdominal pressure. Am J Surg. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double blind trial.

Early antibiotic treatment for severe acute necrotizing pancreatitis: randomized, double-blind, placebo-controlled study. Present and future of prophylactic antibiotics for severe acute pancreatitis. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.

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Ann R Coll Surg Engl. Fungal infections in patients with infected pancreatic necrosis and pseudocysts: risk factors and outcome. Risk factors for the development of intra-abdominal fungal infections in acute pancreatitis. Persistent early organ failure: defining the high risk group of patients with severe acute pancreatitis. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study.

J Digest Dis. Myburgh JA, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. Zhao X, et al. Noninvasive positive-pressure ventilation in acute respiratory distress syndrome in patients with acute pancreatitis: a retrospective cohort study. Wu X, et al. Effect of transpulmonary pressure-directed mechanical ventilation on respiration in severe acute pancreatitis patient with intraabdominal hypertension.

Zhonghua Yi Xue Za Zhi. Cordemans C. Fluid management in critically ill patients: the role of extravascular lung water, abdominal hypertension, capillary leak, and fluid balance. Ann Intensive Care. Effect and cost of treatment for acute pancreatitis with or without gabexate mesylate: a propensity score analysis using a nationwide administrative database. Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis.

Intern Med ;— Early versus on-demand nasoenteric tube feeding in acute pancreatitis.

12222 WSES guidelines for the management of severe acute pancreatitis

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Nat Rev Gastroenterol Hepatol. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Eastern Association for the Surgery of trauma. J Trauma Acute Care Surg. Debridement and closed packing for sterile or infected necrotizing pancreatitis. Isolated pancreatic tail remnants after transgastric necrosectomy can be observed. J Surg Res. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome.

Surgical decompression for abdominal compartment syndrome in severe acute pancreatitis. Arch Surg. Surgical management of pancreatic necrosis. A step-up approach or open necrosectomy for necrotizing pancreatitis. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Interventions for necrotising pancreatitis. Cochrane upper GI and pancreatic diseases group.

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JAMA Surgery. Routine intraoperative cholangiography seems is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels. Amer J Surg.

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