Liver, Pancreas and Biliary Tract
Predictors of severe and critical acute pancreatitis: A systematic review

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Abstract

Background

Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination.

Methods

We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria.

Results

The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48 h of admission, and blood urea nitrogen and Japanese Severity Score after 48 h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin.

Conclusions

Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48 h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48 h of admission.

Introduction

Prediction of disease severity is one of the most important clinical goals in the management of patients with acute pancreatitis. An accurate marker of severity allows early identification of those patients who require transfer to a referral centre, treatment in an intensive care unit (ICU), and/or specific interventions [1], [2], [3]. The literature is replete with studies investigating predictors for the severity of acute pancreatitis, but these studies are limited by the great variation in their definitions of severity (i.e. what they aim to predict) [4]. Definitions include local and/or systemic complications (as defined by the 1992 Atlanta symposium) [5], infectious pancreatic complications alone, admission to an ICU, length of ICU or hospital stay, complications requiring intervention, grading by radiological imaging [6], and multifactorial prognostic clinico-biochemical scores [7]. It has been argued that improvements in predicting severity of acute pancreatitis can hardly be achieved without agreement on which endpoints should be used [2].

Recent advances in the understanding of the drivers of severity of acute pancreatitis has drawn attention to the importance of persistent organ failure (POF), as well as infected pancreatic and/or peripancreatic necrosis (IPN), as determinants of mortality in patients with acute pancreatitis [8], [9]. As a result, the determinant-based international multidisciplinary classification has been developed [10] and validated [11], [12], [13]. One of the features of the new classification is a new category of acute pancreatitis severity called “critical” acute pancreatitis. This category incorporates patients with both POF and IPN. The new international multidisciplinary classification has also updated the definitions of “severe” acute pancreatitis. This category now incorporates patients with either POF or IPN [10].

Given that POF and/or IPN are the major determinants of mortality in acute pancreatitis, there is an urgent clinical need to determine the best available predictors of these two determinants of severity. To the best of our knowledge, no study has systematically addressed this important clinical question. Thus, the aim of this study is to conduct a systematic literature review to determine the utility of predictors of POF and IPN, both alone and in combination.

Section snippets

Study identification

A search of EMBASE, Cochrane Reviews, and PubMed databases from 1950 to January 2013 was carried out. The search strategy for predictors of POF included “persistent organ failure/ OR multiple organ failure” AND “acute pancreatitis” AND “Predicting/ OR predictor/ OR predict/ OR identify/ OR indicator/ OR indicate/ predictors/ OR sign”. The search strategy for predictors of IPN included “infected pancreatic necrosis/ OR infective pancreatic necrosis/ OR infected necrotizing pancreatitis/ OR

Predictors of POF

A total of 526 studies were assessed for eligibility and 7 studies examining a total of 15 predictors were included in the final review. The flow chart of the selection process is outlined in Fig. 1 (PRISMA diagram). Of the 15 predictors included, 11 were evaluated in more than 1 study. The methodological quality of the included studies was excellent, as 6 of 7 studies reached the maximum score of 11 points (Table 1).

Table 1 lists the characteristics of the studies examining predictors of POF.

Discussion

This is the first systematic literature review that has focused on predictors of POF and IPN in acute pancreatitis. Although numerous reviews have described various predictors of a “severe” course of acute pancreatitis, there was a remarkable heterogeneity between the studies in terms of what they actually aimed to predict [2], [3]. These endpoints for the prediction of “severe” acute pancreatitis included, among others, death, length of hospitalization, ICU admission, and need for surgery. The

Conflict of interest

None declared.

References (41)

  • J.A. Windsor et al.

    Acute pancreatitis reclassified

    Gut

    (2013)
  • E.L. Bradley

    A clinically based classification system for acute pancreatitis

    Summary of the International Symposium on Acute Pancreatitis

    Archives of Surgery

    (1993)
  • G.I. Papachristou et al.

    Comparison of BISAP, Ranson's. APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis

    American Journal of Gastroenterology

    (2010)
  • M.S. Petrov et al.

    Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA). New international classification of acute pancreatitis: more than just 4 categories of severity

    Pancreas

    (2013)
  • M.S. Petrov et al.

    Classification of the severity of acute pancreatitis: how many categories make sense?

    American Journal of Gastroenterology

    (2010)
  • E.P. Dellinger et al.

    Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation

    Annals of Surgery

    (2012)
  • R.B. Thandassery et al.

    Prospective validation of a 4-category classification of acute pancreatitis severity

    Pancreas

    (2013)
  • H. Nawaz et al.

    Revised Atlanta and determinant-based classification: application in a prospective cohort of acute pancreatitis patients

    American Journal of Gastroenterology

    (2013)
  • P. Whiting et al.

    The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews

    BMC Medical Research Methodology

    (2003)
  • J. Zamora et al.

    Meta-DiSc: a software for meta-analysis of test accuracy data

    BMC Medical Research Methodology

    (2006)
  • Cited by (0)

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