Prognostic indicators and management of severe acute pancreatitis
Severe acute pancreatitis (SAP) is defined according to clinicobiological, radiological, and evolutionary criteria. In this review, we discuss the main prognostic factors and propose a therapeutic approach based on recent literature. The treatment of SAP primarily involves resuscitation and intensive care, with surgery reserved as a secondary treatment in the event of complications or cases of biliary etiology. Despite advancements, the prognosis remains guarded for severe forms. A critical challenge in this emergency context is the early identification of markers that can guide patients with severe SAP to referent centers with multidisciplinary and specialized teams. These teams play a dual role: providing optimal acute-phase care and ensuring long-term monitoring due to potential functional consequences that may persist post-crisis.
- Société Nationale Française de Gastro-Entérologie. Consensus conference: Acute pancreatitis. Gastroenterol Clin Biol. 2001;25(2):177-192. doi: 10.MDOI-GCB-02-2001-25-2-0399-8320-101019-ART9
- Wysocki AP, Carter CR. Acute pancreatitis. Surgery (Oxford). 2007;25(2):49-56. doi: 10.1016/j.mpsur.2007.01.004
- Uomo G, Rabitti PG, Laccetti M, et al. Predictive evaluation of acute necrotizing pancreatitis: Results of a prospective study. Presse Med. 1995;24(5):263-266.
- Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111. doi: 10.1136/gutjnl-2012-302779
- Hebuterne X, Schneider S. Artificial nutrition in acute pancretitis. Réanimation. 2008;17(5):462-471. doi: 10.1016/j.reaurg.2008.04.003
- Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. 2006;354(20):2142-2150. doi: 10.1056/NEJMcp054958
- Haney JC, Pappas TN. Necrotizing pancreatitis: Diagnosis and management. Surg Clin North Am. 2007;87(6):1431-1446, ix. doi: 10.1016/j.suc.2007.08.013
- Uomo G, Pezzilli R, Gabbrielli A, et al. Diagnostic assessment and outcome of acute pancreatitis in Italy: Results of a prospective multicentre study. ProInf-AISP: Progetto informatizzato pancreatite acuta, Associazione Italiana Studio Pancreas, phase II. Dig Liver Dis. 2007;39(9):829-837. doi: 10.1016/j.dld.2007.05.009
- Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology. 2016;16(5):698-707. doi: 10.1016/j.pan.2016.07.004
- Werner J, Ühl W, Büchler M. Acute pancreatitis. In: Current Surgical Therapy. 8th ed. Philadelphia PA: Cameron JL; 2004. p. 459-469.
- Masamune A, Kikuta K, Hamada S, et al. Clinical practice of acute pancreatitis in Japan: An analysis of nationwide epidemiological survey in 2016. Pancreatology. 2020;20(4):629-636. doi: 10.1016/j.pan.2020.04.013
- Larvin M, McMahon MJ. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet. 1989;2(8656):201-205. doi: 10.1016/s0140-6736(89)90381-4
- Compañy L, Sáez J, Martínez J, et al. Factors predicting mortality in severe acute pancreatitis. Pancreatology. 2003;3(2):144-148. doi: 10.1159/000070083
- Papachristou GI, Papachristou DJ, Morinville VD, Slivka A, Whitcomb DC. Chronic alcohol consumption is a major risk factor for pancreatic necrosis in acute pancreatitis. Am J Gastroenterol. 2006;101(11):2605-2610. doi: 10.1111/j.1572-0241.2006.00795.x
- Papachristou GI, Papachristou DJ, Avula H, Slivka A, Whitcomb DC. Obesity increases the severity of acute pancreatitis: Performance of APACHE-O score and correlation with the inflammatory response. Pancreatology. 2006;6(4):279-285. doi: 10.1159/000092689
- Meyers MA, Feldberg MA, Oliphant M. Grey Turner’s sign and Cullen’s sign in acute pancreatitis. Gastrointest Radiol. 1989;14(1):31-37. doi: 10.1007/BF01889150
- Rosas JMH, Soto SN, Aracil JS, et al. Intra-abdominal pressure as a marker of severity in acute pancreatitis. Surgery. 2007;141(2):173-178. doi: 10.1016/j.surg.2006.04.016
- Büchler M, Malfertheiner P, Schoetensack C, Uhl W, Beger HG. Sensitivity of antiproteases, complement factors and C-reactive protein in detecting pancreatic necrosis. Results of a prospective clinical study. Int J Pancreatol. 1986;1(3-4):227-235. doi: 10.1007/BF02795248
- Rau B, Schilling MK, Beger HG. Laboratory markers of severe acute pancreatitis. Dig Dis. 2004;22(3):247-257. doi: 10.1159/000082796
- Werner J, Hartwig W, Uhl W, Müller C, Büchler MW. Useful markers for predicting severity and monitoring progression of acute pancreatitis. Pancreatology. 2003;3(2):115-127. doi: 10.1159/000070079
- Mayer JM, Raraty M, Slavin J, et al. Serum amyloid A is a better early predictor of severity than C-reactive protein in acute pancreatitis. Br J Surg. 2002;89(2):163-171. doi: 10.1046/j.0007-1323.2001.01972.x
- Bülbüller N, Doğru O, Ayten R, Akbulut H, Ilhan YS, Cetinkaya Z. Procalcitonin is a predictive marker for severe acute pancreatitis. Ulus Travma Acil Cerrahi Derg. 2006;12(2):115-120.
- Müller CA, Uhl W, Printzen G, et al. Role of procalcitonin and granulocyte colony stimulating factor in the early prediction of infected necrosis in severe acute pancreatitis. Gut. 2000;46(2):233-238. doi: 10.1136/gut.46.2.233
- Mayer J, Rau B, Gansauge F, Beger H. Inflammatory mediators in human acute pancreatitis: Clinical and pathophysiological implications. Gut. 2000;47(4):546-552. doi: 10.1136/gut.47.4.546
- Domínguez-Muñoz JE, Villanueva A, Lariño J, et al. Accuracy of plasma levels of polymorphonuclear elastase as early prognostic marker of acute pancreatitis in routine clinical conditions. Eur J Gastroenterol Hepatol. 2006;18(1):79-83. doi: 10.1097/00042737-200601000-00014
- Sewpaul A, French JJ, Khoo TK, Kernohan M, Kirby JA, Charnley RM. Soluble E-Cadherin: An early marker of severity in acute pancreatitis. HPB Surg. 2009;2009:397375. doi: 10.1155/2009/397375
- Kaya E, Dervişoğlu A, Polat C. Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis. World J Gastroenterol. 2007;13(22):3090-3094. doi: 10.3748/wjg.v13.i22.3090
- Johnson CD, Toh SKC, Campbell MJ. Combination of APACHE-II score and an obesity score (APACHE-O) for the prediction of severe acute pancreatitis. Pancreatology. 2004;4(1):1-6. doi: 10.1159/000077021
- Ueda T, Takeyama Y, Yasuda T, et al. Simple scoring system for the prediction of the prognosis of severe acute pancreatitis. Surgery. 2007;141(1):51-58. doi: 10.1016/j.surg.2006.05.008
- Mofidi R, Duff MD, Madhavan KK, Garden OJ, Parks RW. Identification of severe acute pancreatitis using an artificial neural network. Surgery. 2007;141(1):59-66. doi: 10.1016/j.surg.2006.07.022
- Ding N, Guo C, Li C, Zhou Y, Chai X. An Artificial Neural Networks Model for Early Predicting In-Hospital Mortality in Acute Pancreatitis in MIMIC-III. Biomed Res Int. 2021;2021:e6638919. doi: 10.1155/2021/6638919
- Halonen KI, Leppäniemi AK, Lundin JE, Puolakkainen PA, Kemppainen EA, Haapiainen RK. Predicting fatal outcome in the early phase of severe acute pancreatitis by using novel prognostic models. Pancreatology. 2003;3(4):309-315. doi: 10.1159/000071769
- Wang HP, Chen SC. Upper abdominal ultrasound in the critically ill. Crit Care Med. 2007;35(5 Suppl):S208-S215. doi: 10.1097/01.CCM.0000260632.01170.1F
- Pezzilli R, Billi P, Barakat B, D’Imperio N, Miglio F. Ultrasonographic evaluation of the common bile duct in biliary acute pancreatitis patients: Comparison with endoscopic retrograde cholangiopancreatography. J Ultrasound Med. 1999;18(6):391-394. doi: 10.7863/jum.1999.18.6.391
- Nuernberg D, Ignee A, Dietrich CF. Ultrasound in gastroenterology. Biliopancreatic system. Med Klin (Munich). 2007;102(2):112-126. doi: 10.1007/s00063-007-1003-x
- Bolondi L, Gaiani S, Testa S, Labò G. Gall bladder sludge formation during prolonged fasting after gastrointestinal tract surgery. Gut. 1985;26(7):734-738. doi: 10.1136/gut.26.7.734
- Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: Prognostic value of CT. Radiology. 1985;156(3):767-772. doi: 10.1148/radiology.156.3.4023241
- Lecesne R, Taourel P, Bret PM, Atri M, Reinhold C. Acute pancreatitis: Interobserver agreement and correlation of CT and MR cholangiopancreatography with outcome. Radiology. 1999;211(3):727-375. doi: 10.1148/radiology.211.3.r99jn08727
- Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: Value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. doi: 10.1148/radiology.174.2.2296641
- Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193(2):297-306. doi: 10.1148/radiology.193.2.7972730
- Arvanitakis M, Koustiani G, Gantzarou A, et al. Staging of severity and prognosis of acute pancreatitis by computed tomography and magnetic resonance imaging-a comparative study. Dig Liver Dis. 2007;39(5):473-482. doi: 10.1016/j.dld.2007.01.015
- Takeda K, Yokoe M, Takada T, et al. Assessment of severity of acute pancreatitis according to new prognostic factors and CT grading. J Hepatobiliary Pancreat Sci. 2010;17(1):37-44. doi: 10.1007/s00534-009-0213-4
- Hughes SJ, Papachristou GI, Federle MP, Lee KK. Necrotizing pancreatitis. Gastroenterol Clin North Am. 2007;36(2):313- 323, viii. doi: 10.1016/j.gtc.2007.03.012
- Imrie CW, McKay CJ. The possible role of platelet-activating factor antagonist therapy in the management of severe acute pancreatitis. Baillieres Best Pract Res Clin Gastroenterol. 1999;13(2):357-364. doi: 10.1053/bega.1999.0030
- Leppäniemi A, Tolonen M, Tarasconi A, et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019;14:27. doi: 10.1186/s13017-019-0247-0
- Stigliano S, Sternby H, de Madaria E, Capurso G, Petrov MS. Early management of acute pancreatitis: A review of the best evidence. Dig Liver Dis. 2017;49(6):585-594. doi: 10.1016/j.dld.2017.01.168
- Barale F, Clément C. Acute necrotizing hemorrhagic pancreatitis. Ann Fr Anesth Reanim. 1990;9(3):253-260. doi: 10.1016/s0750-7658(05)80182-0
- Yan F, Wang P, Xiong Z, et al. Pulmonary artery catheter in patients with severe acute pancreatitis: A single-center retrospective study. Dig Dis Sci. 2022;67(2):667-675. doi: 10.1007/s10620-021-06881-y
- Vanhorebeek I, Langouche L, Van den Berghe G. Tight blood glucose control with insulin in the ICU: Facts and controversies. Chest. 2007;132(1):268-278. doi: 10.1378/chest.06-3121
- McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: A systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006;30(2):143-156. doi: 10.1177/0148607106030002143
- Heinrich S, Schäfer M, Rousson V, Clavien PA. Evidence-based treatment of acute pancreatitis: A look at established paradigms. Ann Surg. 2006;243(2):154-168. doi: 10.1097/01.sla.0000197334.58374.70
- Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ. 2004;328(7453):1407. doi: 10.1136/bmj.38118.593900.55
- Isenmann R, Rünzi M, Kron M, et al. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: A placebo-controlled, double-blind trial. Gastroenterology. 2004;126(4):997-1004. doi: 10.1053/j.gastro.2003.12.050
- Rau B, Pralle U, Uhl W, Schoenberg MH, Beger HG. Management of sterile necrosis in instances of severe acute pancreatitis. J Am Coll Surg. 1995;181(4):279-288.
- Dellinger EP, Tellado JM, Soto NE, et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: A randomized, double-blind, placebo-controlled study. Ann Surg. 2007;245(5):674-683. doi: 10.1097/01.sla.0000250414.09255.84
- De Waele JJ. Rational use of antimicrobials in patients with severe acute pancreatitis. Semin Respir Crit Care Med. 2011;32(2):174-180. doi: 10.1055/s-0031-1275529
- Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: A meta-analysis. Pancreas. 2001;22(1):28-31. doi: 10.1097/00006676-200101000-00005
- Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: A meta-analysis. J Gastrointest Surg. 1998;2(6):496-503. doi: 10.1016/s1091-255x(98)80048-6
- Villatoro E, Bassi C, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev. 2006;18(4):CD002941. doi: 10.1002/14651858.CD002941.pub2
- Grewe M, Tsiotos GG, Luque de-Leon E, Sarr MG. Fungal infection in acute necrotizing pancreatitis. J Am Coll Surg. 1999;188(4):408-414. doi: 10.1016/s1072-7515(98)00334-2
- He YM, Lv XS, Ai ZL, et al. Prevention and therapy of fungal infection in severe acute pancreatitis: A prospective clinical study. World J Gastroenterol. 2003;9(11):2619-2621. doi: 10.3748/wjg.v9.i11.2619
- Johnson CD, Kingsnorth AN, Imrie CW, et al. Double blind, randomised, placebo controlled study of a platelet activating factor antagonist, lexipafant, in the treatment and prevention of organ failure in predicted severe acute pancreatitis. Gut. 2001;48(1):62-69. doi: 10.1136/gut.48.1.62
- McKay CJ, Curran F, Sharples C, Baxter JN, Imrie CW. Prospective placebo-controlled randomized trial of lexipafant in predicted severe acute pancreatitis. Br J Surg. 1997;84(9):1239-1243.
- Delattre JF, Levy Chazal N, Lubrano D, Flament JB. Percutaneous ultrasound-guided drainage in the surgical treatment of acute severe pancreatitis. Ann Chir. 2004;129(9):497-502. doi: 10.1016/j.anchir.2004.09.006
- Kelly TR, Wagner DS. Gallstone pancreatitis: A prospective randomized trial of the timing of surgery. Surgery. 1988;104(4):600-605.
- Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet. 1988;2(8618):979-983. doi: 10.1016/s0140-6736(88)90740-4
- Fan ST, Lai EC, Mok FP, Lo CM, Zheng SS, Wong J. Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med. 1993;328(4):228-232. doi: 10.1056/NEJM199301283280402
- Fölsch UR, Nitsche R, Lüdtke R, Hilgers RA, Creutzfeldt W. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med. 1997;336(4):237-242. doi: 10.1056/NEJM199701233360401
- Bouvier M, Moussa A. Pancreatic abscess. In: Current Surgical Therapy. Philadelphia, PA: Elsevier Mosby; 2004. p. 476-480.
- Boicean A, Birlutiu V, Ichim C, et al. Predictors of post-ERCP pancreatitis (P.E.P.) in choledochal lithiasis extraction. J Pers Med. 2023;13(9):1356. doi: 10.3390/jpm13091356
- Hungness ES, Robb BW, Seeskin C, Hasselgren PO, Luchette FA. Early debridement for necrotizing pancreatitis: Is it worthwhile? J Am Coll Surg. 2002;194(6):740-744; discussion 744-745. doi: 10.1016/s1072-7515(02)01182-1
- Mier J, León EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173(2):71-75. doi: 10.1016/S0002-9610(96)00425-4
- Howard TJ, Patel JB, Zyromski N, et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg. 2007;11(1):43-49. doi: 10.1007/s11605-007-0112-4
- Chen JH, Huang YM, Chen HT. Is early or late surgical intervention more beneficial in acute necrotizing pancreatitis? Tzu Chi Med J. 2008;20(4):286-290. doi: 10.1016/S1016-3190(08)60052-X
- Malbrain MLN, Cheatham ML, Kirkpatrick A, et al. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med. 2006;32(11):1722-1732. doi: 10.1007/s00134-006-0349-5
- Malbrain MLN, Chiumello D, Pelosi P, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: A multiple-center epidemiological study. Crit Care Med. 2005;33(2):315-322. doi: 10.1097/01.ccm.0000153408.09806.1b
- De Waele JJ, Hoste E, Blot SI, Decruyenaere J, Colardyn F. Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care. 2005;9(4):R452-R457. doi: 10.1186/cc3754
- Rutledge PL, Warshaw AL. Persistent acute pancreatitis. A variant treated by pancreatoduodenectomy. Arch Surg. 1988;123(5):597-600. doi: 10.1001/archsurg.1988.01400290079013
- Bradley EL 3rd. A fifteen year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet. 1993;177(3):215-222.
- Howard TJ, Rhodes GJ, Selzer DJ, Sherman S, Fogel E, Lehman GA. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery. 2001;130(4):714- 719; discussion 719-721. doi: 10.1067/msy.2001.116675
- Büchler MW, Gloor B, Müller CA, Friess H, Seiler CA, Uhl W. Acute necrotizing pancreatitis: Treatment strategy according to the status of infection. Ann Surg. 2000;232(5):619-626. doi: 10.1097/00000658-200011000-00001
- Rau B, Bothe A, Beger HG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: Changing patient characteristics and outcome in a 19-year, single-center series. Surgery. 2005;138(1):28-39. doi: 10.1016/j.surg.2005.03.010
- Fagniez PL, Rotman N, Kracht M. Direct retroperitoneal approach to necrosis in severe acute pancreatitis. Br J Surg. 1989;76(3):264-267. doi: 10.1002/bjs.1800760316
- Šileikis A, Beiša V, Beiša A, Samuilis A, Šerpytis M, Strupas K. Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis. Wideochir Inne Tech Maloinwazyjne. 2013;8(1):29-35. doi: 10.5114/wiitm.2011.30943
- Risse O, Auguste T, Delannoy P, Cardin N, Bricault I, Létoublon C. Percutaneous video-assisted necrosectomy for infected pancreatic necrosis. Gastroenterol Clin Biol. 2004;28(10 Pt 1):868-871. doi: 10.1016/s0399-8320(04)95150-0
- Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: An initial experience. Ann Surg. 2000;232(2):175-180. doi: 10.1097/00000658-200008000-00004
- Cao F, Li A, Wang X, Gao C, Li J, Li F. Laparoscopic transgastric necrosectomy in treatment of walled-off pancreatic necrosis with sinistral portal hypertension. BMC Surg. 2021;21(1):362. doi: 10.1186/s12893-021-01361-6
- Paloyan D, Simonowitz D, Skinner DB. The timing of biliary tract operations in patients with pancreatitis associated with gallstones. Surg Gynecol Obstet. 1975;141(5):737-739.
- Riaz C, Ochi K, Tanaka J, Harada H, Ichimura M, Miki H. Does recurrent acute pancreatitis lead to chronic pancreatitis? Sequential morphological and biochemical studies. Pancreas. 1997;14(4):334-341. doi: 10.1097/00006676-199705000-00002
- Nordback I, Pelli H, Lappalainen-Lehto R, Järvinen S, Räty S, Sand J. The recurrence of acute alcohol-associated pancreatitis can be reduced: A randomized controlled trial. Gastroenterology. 2009;136(3):848-855. doi: 10.1053/j.gastro.2008.11.044
- Yasuda T, Ueda T, Takeyama Y, et al. Long-term outcome of severe acute pancreatitis. J Hepatobiliary Pancreat Surg. 2008;15(4):397-402. doi: 10.1007/s00534-007-1266-x
- Uomo G, Gallucci F, Madrid E, Miraglia S, Manes G, Rabitti PG. Pancreatic functional impairment following acute necrotizing pancreatitis: Long-term outcome of a non-surgically treated series. Dig Liver Dis. 2010;42(2):149-152. doi: 10.1016/j.dld.2009.08.007
- Niederau C, Lüthen R, Häussinger D. Long-term outcome after acute necrotizing pancreatitis. In: Büchler MW, Uhl W, Malfertheiner P, editor. Acute Pancreatitis-Novel Concepts in Biology and Therapy. Oxford,UK: Blackwell Science; 1999.
- Kahl S, Malfertheiner P. Exocrine and endocrine pancreatic insufficiency after pancreatic surgery. Best Pract Res Clin Gastroenterol. 2004;18(5):947-955. doi: 10.1016/j.bpg.2004.06.028
- Fernández-Cruz L, Navarro S, Castells A, Sáenz A. Late outcome after acute pancreatitis: Functional impairment and gastrointestinal tract complications. World J Surg. 1997;21(2):169-172. doi: 10.1007/s002689900210
- Malangoni MA, Martin AS. Outcome of severe acute pancreatitis. Am J Surg. 2005;189(3):273-277. doi: 10.1016/j.amjsurg.2004.11.013
- Wu BU, Johannes RS, Kurtz S, Banks PA. The impact of hospital-acquired infection on outcome in acute pancreatitis. Gastroenterology. 2008;135(3):816-820. doi: 10.1053/j.gastro.2008.05.053