Mofidi R, Duff MD, Wigmore SJ, et al. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis

Department of Clinical and Surgical Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SA, UK.
British Journal of Surgery (Impact Factor: 5.54). 06/2006; 93(6):738-44. DOI: 10.1002/bjs.5290
Source: PubMed


Mortality in patients with acute pancreatitis is associated with the number of failing organs and the severity and reversibility of organ dysfunction. The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis.
Data for all patients with a diagnosis of acute pancreatitis between January 2000 and December 2004 were reviewed. Serum C-reactive protein (CRP), Acute Physiology And Chronic Health Evaluation (APACHE) II scores and presence of SIRS were recorded on admission and at 48 h. Marshall organ dysfunction scores were calculated during the first week of presentation. Presence of SIRS and raised serum CRP levels on admission and at 48 h were correlated with the cumulative organ dysfunction scores in the first week.
A total of 759 patients with acute pancreatitis were identified, of whom 45 (5.9 per cent) died during the index admission. SIRS was identified in 162 patients on admission and was persistent in 138 at 48 h. The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS (4 (0-12), 3 (0-7) and 0 (0-9) respectively; P < 0.001). Thirty-five patients (25.4 per cent) with persistent SIRS died from acute pancreatitis, compared with six patients (8 per cent) with transient SIRS and four (0.7 per cent) without SIRS (P < 0.001). No correlation was observed between CRP level on admission and Marshall score (P = 0.810); however, there was a close correlation between CRP level at 48 h and Marshall score (P < 0.001).
Persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.

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    • "The exact mechanisms by which diverse etiological factors induce an attack are still unclear, while it is generally believed that the release of a variety of inflammatory mediators causes a cascadelike reaction and leads to systemic inflammatory response syndrome (SIRS). An excessive SIRS leads to distant organ damage and multiple organ dysfunction syndrome (MODS), which established the role played by inflammatory mediators in the aggravation of AP and the resultant fatal condition [3] [4] [5]. "
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    ABSTRACT: Background: The use of corticosteroid in the management of severe acute pancreatitis (SAP) remains contentious and is still being debated despite many pre-clinical studies demonstrating benefits. The limitations of clinical research on corticosteroid in SAP are disparities with regard to benefit, a lack of adequate safety data and insufficient understanding of its mechanisms of action. Thus, we performed a meta-analysis to assess the effectiveness of corticosteroid in experimental SAP and take a closer look at the relation between the animal studies and prospective trials. Methods: Studies investigating corticosteroid use in rodent animal models of SAP were identified by searching multiple three electronic databases through October 2013, and by reviewing references lists of obtained articles. Data on mortality, changes of ascitic fluid and histopathology of pancreas were extracted. A random-effects model was used to compute the pooled efficacy. Publication bias and sensitivity analysis were also performed. Results: We identified 15 published papers which met our inclusion criteria. Corticosteroid prolonged survival by a factor of 0.35 (95% CI 0.21-0.59). Prophylactic use of corticosteroid showed efficacy with regards to ascitic fluid and histopathology of pancreas, whereas therapeutic use did not. Efficacy was higher in large dose and dexamethasone groups. Study characteristics, namely type of steroids, rout of delivery, genders and strains of animal, accounted for a significant proportion of between-study heterogeneity. No significant publication bias was observed. Conclusions: On the whole, corticosteroids have showed beneficial effects in rodent animal models of SAP. Prophylactic use of corticosteroid has failed to validate usefulness in prophylaxis of postendoscopic retrogradcholangiopancreatography pancreatitis. Further appropriate and informative animal experiments should be performed before conducting clinical trials investigating therapeutic use in SAP.
    Full-text · Article · Aug 2014 · International journal of clinical and experimental pathology
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    • "About fifteen percent of the patients develop severe disease defined by development of persistent organ failure [1]. The mortality in acute pancreatitis is mainly associated with multiple organ failure [2] whereas the risk of dying is minimal in patients with no or transient organ dysfunction [3,4]. In acute pancreatitis, multiple organ failure is a consequence of excessive activation of a systemic inflammatory response cascade [5]. "
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    ABSTRACT: Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.
    Full-text · Article · Feb 2014 · World Journal of Emergency Surgery
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    • "BISAP incorporates f ive parameters: blood urea nitrogen > 25 mg/dL, impaired mental status, systemic inflammatory response syndrome (SIRS), age > 60 years, and detection of pleural effusion by imaging [17,18]. SIRS is defined by the presence of at least two of the following: pulse > 90 beats per minute, respirations > 20 per minute, PaCO2 < 32 mmHg, temperature > 38℃ or < 37℃, and white blood cell count > 12,000 or < 4,000 cells/mm3, or > 10% immature neutrophils (bands) [19,20]. A prospective validation of the BISAP scoring system as a method for the early detection of severe AP was published recently, and concluded that it is a reliable, accurate means for stratifying patients with AP [17] and that it was an accurate and convenient method of risk stratification compared with other multifactorial scoring systems in patients with AP [21]. "
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    ABSTRACT: BACKGROUNDAIMS: The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic multifactorial scoring system. As more data are needed before clinical application, we compared BISAP, the serum procalcitonin (PCT), and other multifactorial scoring systems simultaneously. Fifty consecutive acute pancreatitis patients were enrolled prospectively. Blood samples were obtained at admission and after 48 hours and imaging studies were performed within 48 hours of admission. The BISAP score was compared with the serum PCT, Ranson's score, and the acute physiology and chronic health examination (APACHE)-II, Glasgow, and Balthazar computed tomography severity index (BCTSI) scores. Acute pancreatitis was graded using the Atlanta criteria. The predictive accuracy of the scoring systems was measured using the area under the receiver-operating curve (AUC). The accuracy of BISAP (≥ 2) at predicting severe acute pancreatitis was 84% and was superior to the serum PCT (≥ 3.29 ng/mL, 76%) which was similar to the APACHE-II score. The best cutoff value of BISAP was 2 (AUC, 0.873; 95% confidence interval, 0.770 to 0.976; p < 0.001). In logistic regression analysis, BISAP had greater statistical significance than serum PCT. BISAP is more accurate for predicting the severity of acute pancreatitis than the serum PCT, APACHE-II, Glasgow, and BCTSI scores.
    Full-text · Article · May 2013 · The Korean Journal of Internal Medicine
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