Prognostic markers in acute pancreatitis

Abstract

Acute pancreatitis has a mortality rate of 5–10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

Keywords::

• acute pancreatitis
• markers
• pancreatic necrosis
• prognosis
• severity

Financial & competing interests disclosure

This work was supported by the NIHR Liverpool Pancreas Biomedical Research Unit. JP Neoptolemos is also a Senior NIHR Investigator. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Acute pancreatitis is a life-threatening illness with mortality rates of 5–10%.

• Approximately 20% of patients develop persisting organ failure proving fatal in 15–20%.

• There are two phases with early death mainly due to multiorgan failure and late deaths due to septic complications from pancreatic necrosis.

• The 2012 revision of the original Atlanta Classification provides a more accurate description of interstitial edematous and necrotizing pancreatitis, its severity and a description of its local complications. It uses the modified Marshall scoring system for organ dysfunction.

• The Determinant Classification is also very similar to the original Atlanta Classification but is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. It uses the sepsis-related organ failure assessment scoring system for organ dysfunction and unlike the 2012 Revised Atlanta Classification includes infected necrosis as criterion of severity.

• Systemic complications are defined in both of the new classifications by organ failure in the respiratory, cardiovascular and renal organ systems, requiring intensive therapy unit support.

• There is a much higher frequency of necrosis classification using the new systems compared with the 1992 Atlanta Classification.

• Intra-abdominal complications require diagnosis and monitoring using contrast-enhanced computed tomography and intervention using minimally invasive techniques.

• In the last 40 years, numerous prognostics systems and markers have been evaluated, but only the eight-factor Glasgow system (excludes transaminase) for the first 48 h provides a reasonable prognostic accuracy and serum C-reactive protein measurements provide good prognostication early on and an important means of severity assessment from 48 h onward. However, both are far from ideal in providing early accurate prognostication (both ∼ 80%).

• No single laboratory marker or composite score is ideal in predicting the severity of pancreatitis.

• The development of a marker that reliably predicts mortality at presentation or very shortly thereafter is a high priority.

Notes