Pancreatitis aguda. Diagnóstico y enfrentamiento inicial en la práctica clínica / Acute pancreatitis. Diagnosis and initial approach in clinical practice

Acute pancreatitis is a prevalent disease, with variable clinical course: several patients recover quickly and uneventfully, while others require treatment in critical care units with long hospital stay and even with a considerable mortality. The patient's symptoms, laboratory tests and radiological images allow diagnosis without major difficulties. However, early identification of more severe cases can be difficult, and it determines the adequate selection of the hospitalization unit and the quick initiation of the appropriate therapy. In this paper we give some practical treatment guidelines for the everyday clinical practice: immediate severity stratification, fluid replacement and pain control. Early enteral nutrition, monitorization of severe cases in critical care units, adequate therapeutic but no prophylactic use of antibiotics assures the best treatment results. (AU)

Um caso raro de destruição total do pâncreas por pancreatite em cão / A rare case of total pancreatic destruction due to pancreatitis in a dog

A 16-year-old female Poodle entered UFMG's Veterinary Hospital with severe prostration, lack of appetite, and vomit. During physical examination, abdominal pain, dehydration, and hyperglycemia (448mg/dl) were found, therefore the animal was admitted under the suspicion of diabetic ketoacidosis. Screening revealed metabolic acidosis, hyperkalemia, glycosuria, ketonuria, and proteinuria. Leukocytosis, thrombocytosis, increase in the number of hepatic enzymes and hyperglycemia were also present in these tests. The ultrasound images showed a smaller and hypoechogenic pancreas, irregularity and folds in duodenum and reactivity of the surrounding tissue, indicating pancreatitis. Thirty days after the dog had been discharged for treatment at home, it was taken back to the veterinary hospital due to status epilepticus, which motivated the owner's decision of euthanasia. During post mortem examination no trace of pancreas was found. On histological examination of the adipose tissue next to the duodenum, only one pancreatic duct was seen, together with inflamatory cells , thus characterizing a rare case of total pancreatic destruction due to pancreatitis.(AU)

Understanding the international consensus for acute pancreatitis: classification of atlanta 2012 / Entendendo o consenso internacional para as pancreatites agudas: classificação de atlanta 2012

ABSTRACT Introduction: Contrast computed tomography and magnetic resonance imaging are widely used due to its image quality and ability to study pancreatic and peripancreatic morphology. The understanding of the various subtypes of the disease and identification of possible complications requires a familiarity with the terminology, which allows effective communication between the different members of the multidisciplinary team. Aim: Demonstrate the terminology and parameters to identify the different classifications and findings of the disease based on the international consensus for acute pancreatitis ( Atlanta Classification 2012). Methods: Search and analysis of articles in the "CAPES Portal de Periódicos with headings "acute pancreatitis" and "Atlanta Review". Results: Were selected 23 articles containing radiological descriptions, management or statistical data related to pathology. Additional statistical data were obtained from Datasus and Population Census 2010. The radiological diagnostic criterion adopted was the Radiology American College system. The "acute pancreatitis - 2012 Rating: Review Atlanta classification and definitions for international consensus" tries to eliminate inconsistency and divergence from the determination of uniformity to the radiological findings, especially the terminology related to fluid collections. More broadly as "pancreatic abscess" and "phlegmon" went into disuse and the evolution of the collection of patient fluids can be described as "acute peripancreatic collections", "acute necrotic collections", "pseudocyst" and "necrosis pancreatic walled or isolated". Conclusion: Computed tomography and magnetic resonance represent the best techniques with sequential images available for diagnosis. Standardization of the terminology is critical and should improve the management of patients with multiple professionals care, risk stratification and adequate treatment.

RESUMO Introdução: A tomografia computadorizada contrastada e a ressonância magnética são exames amplamente utilizados no estudo da morfologia pancreática e peripancreática. O entendimento dos diversos subtipos da doença e identificação de suas possíveis complicações requer familiaridade com a terminologia padrão, a qual permite comunicação efetiva entre os diversos membros da equipe multidisciplinar. Objetivo: Demonstrar terminologia e os parâmetros para identificação das diferentes classificações da doença a partir do consenso internacional para as pancreatites agudas (Classificação de Atlanta 2012. Método: Busca e análise de artigos no "Portal de Periódicos da CAPES" com descritores "pancreatite aguda" e "Revisão de Atlanta". Resultado : Foram selecionados 23 artigos que continham descrições radiológicas, manejo ou dados estatísticos relacionados à doença. Dados estatísticos adicionais foram obtidos no sistema Datasus e Censo Demográfico 2010. O critério de diagnóstico radiológico adotado foi o do Colégio Americano de Radiologia. A "Classificação da pancreatite aguda - 2012: revisão da classificação de Atlanta e definições por consenso internacional" tenta eliminar a inconsistência e divergências a partir da determinação de uniformidade para os achados radiológicos, em especial à terminologia relacionada às coleções de fluidos. Termos mais abrangentes como "abscesso pancreático" e "flegmão" entraram em desuso e a evolução da coleção de fluidos pode ser descrita como: "coleções peripancreáticas agudas", "coleções necróticas agudas", "pseudocisto" e "necrose pancreática murada ou isolada". Conclusão: A tomografia computadorizada e a ressonância magnética representam as melhores técnicas com cortes sequenciais disponíveis para diagnóstico. A adequação da terminologia é ponto crítico e deve permitir o manejo do paciente por múltiplos profissionais, estratificação de risco e adequação de tratamento.

The panc 3 score predicting severity of acute pancreatitis / Escore panc 3 na predição da severidade de pancreatite aguda

Background: About 20% of cases of acute pancreatitis progress to a severe form, leading to high mortality rates. Several studies suggested methods to identify patients that will progress more severely. However, most studies present problems when used on daily practice. Objective: To assess the efficacy of the PANC 3 score to predict acute pancreatitis severity and its relation to clinical outcome. Methods: Acute pancreatitis patients were assessed as to sex, age, body mass index (BMI), etiology of pancreatitis, intensive care need, length of stay, length of stay in intensive care unit and mortality. The PANC 3 score was determined within the first 24 hours after diagnosis and compared to acute pancreatitis grade of the Revised Atlanta classification. Results: Out of 64 patients diagnosed with acute pancreatitis, 58 met the inclusion criteria. The PANC 3 score was positive in five cases (8.6%), pancreatitis progressed to a severe form in 10 cases (17.2%) and five patients (8.6%) died. Patients with a positive score and severe pancreatitis required intensive care more often, and stayed for a longer period in intensive care units. The PANC 3 score showed sensitivity of 50%, specificity of 100%, accuracy of 91.4%, positive predictive value of 100% and negative predictive value of 90.6% in prediction of severe acute pancreatitis. Conclusion: The PANC 3 score is useful to assess acute pancreatitis because it is easy and quick to use, has high specificity, high accuracy and high predictive value in prediction of severe acute pancreatitis.

Racional: Cerca de 20% dos casos de pancreatite aguda evoluem de forma severa, acompanhados de alta mortalidade. Diversos estudos têm sugerido métodos para identificar pacientes que evoluirão com maior gravidade. Entretanto, a maioria apresenta problemas em sua utilização na prática diária. Objetivo: Avaliar a eficácia do escore PANC 3 na predição da severidade da pancreatite aguda e sua relação com o desfecho clínico. Métodos: Pacientes com pancreatite aguda foram avaliados quanto ao sexo, idade, índice de massa corporal (IMC), etiologia da pancreatite, necessidade de cuidados intensivos, tempo de internação hospitalar, período necessário de cuidados intensivos e mortalidade. O escore PANC 3 foi determinado nas primeiras 24 h do diagnóstico e comparado ao grau de pancreatite aguda da classificação de Atlanta Revisada. Resultados: Dos sessenta e quatro pacientes, cinquenta e oito preencheram os critérios necessários para inclusão no estudo. O escore PANC 3 foi positivo em cinco casos (8,6%), a pancreatite evoluiu de forma severa em 10 (17,2%) e 5 (8,6%) faleceram. Pacientes com escore positivo e pancreatite severa, necessitaram mais frequentemente de cuidados intensivos e, quando necessitaram, permaneceram por período maior nas unidades de cuidados intensivos. O escore PANC 3 demonstrou sensibilidade de 50%, especificidade de 100%, acurácia de 91,4%, valor preditivo positivo de 100% e valor preditivo negativo de 90,6% na predição de pancreatite aguda severa. Conclusão: O escore PANC 3 é útil na abordagem da pancreatite aguda, por ser de fácil e rápida aplicação, apresentar alta especificidade, alta acurácia e alto valor preditivo na predição da pancreatite aguda severa.

Classificação de gravidade na pancreatite aguda / Classification of severity of acute pancreatitis

De acordo com a Classificação de Atlanta a pancreatite aguda pode ser dividida, baseado em sua severidade, em uma forma leve ou grave. Uma série de aspectos têm sido discutidos nos últimos anos, tais como, quantas categorias de gravidade devem ser consideradas; se o doente com falência orgânica é igual ao doente com necrose infectada; qual o papel da falência orgânica transitória; e como avaliar a falência orgânica. A reunião de revista"Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma avaliação crítica de artigos relacionados a este tema, considerando três artigos recentes que delinearam duas grandes revisões publicadas nos últimos meses. Estes artigos sugerem a classificação de gravidade em três ou quatro categorias, ao invés de pancreatite aguda leve ou grave, além de discutir qual o melhor escore para avaliar a falência orgânica. As seguintes recomendações foram propostas: (1) A pancreatite aguda deve ser classificada em quatro categorias: leve, moderada, grave e crítica, o que permite uma melhor determinação das características dos doentes; (2) Avaliação de falência orgânica com um escore de gravidade, preferencialmente algum que avalie diretamente cada falência orgânica, tais como o SOFA e o MODS (Marshall). O SOFA parece ter maior acurácia, mas o MODS tem melhor aplicabilidade devido à facilidade de uso.

Based on the Atlanta Classification, acute pancreatitis is classified according to its severity in either mild or severe acute pancreatitis. In recent years, several issues regarding acute pancreatitis have been discussed in the literature. These issues include how many categories of severity should be considered; whether or not a patient with organ failure holds similar holds severity of disease and prognosis of a patient with infected necrosis; the role of transient organ failure; and how to evaluate organ failure. The"Evidence-based Telemedicine - Trauma and Acute Care Surgery" (EBT-TACS) conducted a review of the recent literature on the topic, and critically appraised its most relevant pieces of evidence.. The articles discussed suggested classifying the severity of acute pancreatitis in three or four categories, rather than mild or severe only, and addressed which is the best score to assess organ failure. The following recommendations were proposed: (1) Acute pancreatitis should be classified into four categories: mild, moderate, severe and critical, which allows a better determination of the characteristics of patients, (2) Evaluation of organ failure with a severity score that preferably evaluate directly each organ failure, such as the SOFA and MODS (Marshall). The SOFA seems to have greater accuracy, but the MODS has better applicability due to its ease of use.

Manejo da pancreatite biliar aguda / Management of acute biliary pancreatitis

Este artigo tem como objetivo abordar aspectos relacionados à pancreatite biliar aguda com foco no seu tratamento. A conduta será definida a partir da gravidade do quadro, sendo a pancreatite classificada em leve ou grave.

This article aims to approach issues related to acute biliary pancreatitis with a focus on treatment. The line will be defined from the severity of pancreatitis classified as mild or severe.

Early computerized tomographic scan in mild pancreatitis may be deceiving: an experience of tertiary care hospital

To assess the justification of Computerized Tomographic [CT] scan for the diagnosis of acute pancreatitis at early stage and its impact on mortality and morbidity of patients. It was a retrospective study conducted at Radiology Department Dow University of Health Sciences from April 2009 to August 2011. Patients were diagnosed as acute pancreatitis both clinically and radiologically. Severity of acute pancreatitis was clinically assessed by Ranson's criteria and radiologically by Balthazar CT Grading and CT Severity Index. Fourteen of the total 131 included patients underwent early CT scan at 4-12 hour after start of symptoms of abdominal pain and vomiting and were normal radiologically[10.68% out of total 131 patients presented with acute pancreatitis. These patients revisited at 24-36 hours, with severe epigastric pain and on follow-up CT scan on re-admission, two patients showed intra and peripancreatic collections, swollen pancreas with peripancreatic fat necrosis without necrotizing pancreatitis [Balthazar Grade-E] and moderate pancreatitis according to CT Severity Index[four points]; Three patients had 30% pancreatic necrosis with Balthazar grade-E changes and according to CT Severity Index moderate pancreatitis[2+4=6]; Two patients had 30-50% necrosis and rated as Balthazar Grade-E and labeled as severe necrotizing pancreatitis according to CT Severity Index[4+4=8]; while Seven patients showed severe necrotizing pancreatitis with >50% of pancreatic necrosis according to CT Severity Index[6+4] along with Balthazar Grade-E pancreatitis[6+4=10]. Patients with severity index of 10 had 100% mortality. Early CT scan has very little role in diagnosing and determining severity of disease or in predicting prognosis of patients.

Changing Pattern of Incidence; Aetiology and Mortality from Acute Pancreatitis at Kalafong Hospital; Pretoria; South Africa;1988-2007: A Retrospective Evaluation

Background: Literature reports from Western countries suggest an increasing incidence of acute pancreatitis (AP) and changing pattern over the past two decades. The aim of thisstudy was to document the incidence; aetiology and mortality from AP over two decades and to examine any emerging trends.Methods: A retrospective study of all confirmed cases of AP admitted over a 20-year period to thesurgical department was performed. Patients' demographics; year of admission;number of attacks; aetiology; management and outcome were entered on a specialstudy proforma.Results: Altogether 707 attacks of AP (M: F; 5.7: 1) were recorded. The proportion of gallstone APincreased (3.1to 12.7) and that of alcohol-related AP decreased (84to 67.6). Alcohol was themain aetiological factor for AP. Drugs; hyperlipidaemia; human immunodeficiency virus (HIV) andendoscopic pancreatography-related AP increased in the second decade. The in-hospital mortality rateduring the respective periods was 6.5and 3.1.Conclusion: Gallstone AP increased during second decade from more Caucasian admissions and increased gallstones among Blacks. The reduced mortality was attributed to changing trends in the nature and aetiology of AP recorded; heightened awareness of the condition and improved management

Pancreatitis aguda / Acute pancreatitis in pediatric patients

The objective is to review current concepts about acute pancreatitis in children, in terms of etiology, clinical aspects, diagnosis, prognosis and new therapies. Acute pancreatitis (AP) is an inflammatory disease caused by the activation, interstitial liberation and autodigestion of pancreatic tissue by its own enzymes. The etiologies of AP in children are trauma, infections, toxics, biliary tract obstruction, genetic, metabolic, systemic disease and idiopathics. In the majority of cases, they constitute a benign self-limited process with good prognosis. The 1992 Atlanta Classification establishes the categories of mild AP, severe AP, necrosis, acute liquid collection, pseudocyst and pancreatic abscess. The most important symptoms include abdominal pain, vomiting and fever. The hematologic and bioquimics analysis have a prognostic value, while the diagnosis is confirmed by enzymatic and imagenologic study. The treatment is supportive, based on monitorization, enteral rest and appropriate pain analgesia. According to the etiology and severity of the case, other therapies should be used, like endovenous antibiotics, surgical intervention of the biliary pathology or pseudocyst, abscess or necrosis and, finally, the use of new drugs including Octeotride, Lexipafant, antioxidant agents and pancreatic enzymes.

El objetivo de este artículo es actualizar el conocimiento de aspectos etiológicos, clínicos y diagnósticos de la pancreatitis aguda en niños, así como también de factores pronósticos y nuevas terapias disponibles. La pancreatitis aguda es una enfermedad inflamatoria, originada por la activación, liberación intersticial y la autodigestion de la glándula pancreática por sus propias enzimas. La mayoría de los casos en niños son cuadros autolimitados y de buen pronóstico. La clasificación de Atlanta de 1992 define los conceptos de pancreatitis aguda leve, grave, necrosis, colecciones líquidas agudas, pseudoquistes y absceso pancreático. Las etiologías en los casos de pancreatitis aguda infantil son diversas, entre las cuales se cuentan: traumáticas, infecciosas, tóxicas, secundarias a obstrucción de la vía biliar, hereditarias, metabólicas, asociadas a enfermedades sistémicas e idiopáticas. Los síntomas más relevantes son el dolor abdominal, los vómitos y la fiebre. Para confirmar el diagnóstico se requiere de un estudio enzimático e imagenológico. Los exámenes hematológicos y bioquímicos tienen valor pronóstico. El tratamiento se basa en monitorización, reposo enteral y apoyo analgésico, y dependiendo de la etiología y gravedad del cuadro serán instauradas otras terapias tales como antibióticos, manejo quirúrgico de la patología biliar o de los pseudoquistes, abscesos y necrosis pancreática, y finalmente el empleo de nuevos fármacos tales como octeotride, lexipafant, agentes antioxidantes y enzimas pancreáticas.

Superioridad del derrame pleural sobre los criterios múltiples en el pronóstico de la pancreatitis aguda biliar / Pleural effusion is superior to multiple factor scoring system in predicting acute pancreatitis outcome

Introducción: existen numerosos trabajos sobre sistemas pronósticos en pancreatitis aguda. Sin embargo, todavía existe controversia sobre cuál es el mejor sistema pronóstico. Objetivo: analizar la exactitud pronóstica de la presencia de derrame pleural evaluada por ecografía al ingreso y compararla con tres sistemas de criterios múltiples (RANSON, APACHE II; APACHE II O). Pacientes y métodos: ingresaron al estudio todos los pacientes con diagnóstico de pancreatitis aguda biliar en el período 2002 a 2006. Se excluyeron pacientes en los que se realizaron CPRE temprana y aquellos en los cuales no se pudo realizar ecografía al ingreso. Se determinó la severidad del ataque de acuerdo a los criterios de Atlanta. Los sistemas pronósticos estudiados fueron evaluados para predecir en forma independiente complicaciones sistémicas, complicaciones locales y complicaciones totales (sistémicas más locales). Se utilizó la razón de verosimilitud como índice más adecuado para comparar la exactitud pronóstica de los 4 sistemas pronósticos evaluados. Resultados: ingresaron al estudio 178 pacientes, se excluyeron 35 (CPRE temprana=32, imposibilidad de ecografía al ingreso= 3). De los 143 pacientes estudiados, 29 pacientes (20, 2%) desarrollaron pancreatitis aguda grave. El derrame pleural evaluado por ecografía presentó valores superiores de exactitud pronóstica en la predicción de complicaciones sistémicas (razón de verosimilitud= 6,3), complicaciones locales (razón de verosimilitud= 11) y complicaciones totales (razón de verosimilitud= 16,1). Conclusión: la evaluación de la presencia de derrame pleural por ecografía predijo con aceptables cifras de razón de verosimilitud la presencia de un ataque grave. El derrame pleural por ecografía mostró cifras superiores de razón de verosimilitud cuando se lo comparó con 3 sistemas de criterios múltiples (RANSON, APACHE II y APACHE II O).

Introduction: there are many studies about prognostic scores in acute pancreatitis but the best one has yet to be determined. Objective: to analyze the pleural effusion (diagnosed by ultrasound) as a prognostic factor and to compare it with three multiple criteria scores (RANSON, APACHE II, APACHE II O). Patients and Methods: all patients with acute gallstone pancreatitis were included in the study during the period 2002- 2006. Patients treated with ERCP at admission and those in whom ultrasonography was not done were excluded. The severity of the attack was set according to the Atlanta Classification criteria. The prognostic scores used were analyzed to predict separately systemic complications, local complications and total complications (local and systemic). The likelihood positive ratio was used as the most accurate index to compare the prognostic accuracy of the 4 prognostic scores. Results: 178 patients were included. 35 patients were excluded (ERCP at admission=32, ultrasonography not done at admission=3). 29 patients of 143 patients developed severe acute pancreatitis. The pleural effusion evaluated by ultrasonography showed the great accuracy at predicting the development of systemic complications (likelihood positive ratio=6.3), local complications (likelihood positive ratio=11) and total complications (likelihood positive ratio=16.1). Conclusion: the pleural effusion evaluated by ultrasonography can predict with great levels of accuracy a severe acute attack. When it was compared with 3 multiple criteria scores (RANSON, APACHE II, APACHE II O) showed to be more accurate at predicting disease severity.

Tropical pancreatitis - a distinct entity, or merely a type of chronic pancreatitis?

Tropical pancreatitis was described 50 years ago as a disease of the tropical regions, particularly southern India, with young age at onset, malnutrition, rapid progression, severe pancreatic damage with multiple large ductal calculi, and absence of history of alcoholism or biliary tract disease as its hallmarks. Over the years, chronic pancreatitis in southern India has shown a change, with increase in older patients, occurrence of milder disease including milder diabetes, increasing longevity, and increasing association with alcoholism and smoking. This article looks at changes in the disease and in dietetic, environmental and socioeconomic factors over the years, in an attempt to understand the environment-gene interactions in its causation. This analysis shows that tropical pancreatitis may represent one end of the wide spectrum of chronic pancreatitis in the tropics, with alcoholic pancreatitis representing the other extreme.

Tratamento clínico e cirúrgico da pancreatite biliar aguda / The clinic and surgical treatment of acute gallstone pancreatitis

Pancreatite Aguda (PA) é patologia relativamente comum, que na maioria das vezes evolui de forma benigna, mas em cerca de 10-20 por cento dos casos pode manifestar-se de forma severa, levando à alta morbimortalidade. Sua estratificação em riscos, bem como sua abordagem terapêutica, permanecem como um desafio ao clínico ou cirurgião. O objetivo dessa revisão bibliográfica é discutir a fisiopatologia, diagnóstico, classificação clínica e, principalmente, o tratamento da Pancreatite Blliar Aguda (PBA), a mais freqüente em nosso meio

Clasificación actual de la pancreatitis aguda: una aproximación clínico radiológica / Current classification of the acute pancreatitis: a clinical radiologic approach

El rol de la radiología en el diagnóstico de la pancreatitis aguda (PA) y de sus complicaciones ya ha sido establecido. Las distintas clasificaciones que se han creado para determinar la gravedad de esta enfermedad (dentro de ellas la más conocida es la de Balhtazar) no se correlacionan adecuadamente con el manejo ni con el pronóstico del paciente. Por otra parte, muchos de los términos clínico-radiológicos para caracterizar las PA, no son ampliamente aceptados y más aún, son definidos en forma distintas por los diversos autores. El año 1992 el simposio sobre PA en Atlanta estableció una nueva clasificación con el fin de unificar criterios. Esta clasificación es usada en forma sistemática desde el año 1998 en el Hospital Clínico de la Universidad de Chile, existiendo una buena correlación con la evolución clínica de los pacientes. Se presenta la clasificación de Atlanta 1992, para su difusión y discusión en el resto de los servicio de imágenes del país

Prognostic classification and management of local complications of severe acute pancreatitis

Recently, an international symposium on acute pancreatitis developed a clinically based classification system for acute pancreatitis that classifies its local complications into three groups [sterile necrosis [SN], infected necrosis [IV] and pancreatic abscess [PA]]. The aim of this study was to investigate the prognostic and therapeutic utility of applying this clinical classification to a group of surgical patients with local complications from acute pancreatitis. Twenty-two patients with locally complicated pancreatitis were managed and classified into three groups [sterile necrosis [SN], infected necrosis [IN] and pancreatic abscess]. Ranson's score, APACHE-II score and computed tomography [CT] grading were calculated within the first 48 hours of admission. Information about the patients' demographics, timing of intervention, bacteriology, blood loss, intensive care unit days, ventilator days and morbidity and mortality were also reviewed and analyzed. It was found that the clinical classification had both therapeutic and prognostic utility. The adoption of this system should allow for a standardization of interinstitutional data and provide a framework for more accurate and precise communication between clinicians

Pancreatitis aguda: nueva nomenclatura / Acute pancreatitis: new nomenclature

Se revisa la historia de los diferentes sistemas de clasificación que se han empleado para definir la pancreatitis aguda y sus complicaciones. La clasificación propuesta en Atlanta en 1992 se basa principalmente en la clínica, lo cual es útil a los médicos tratantes en general y es frecuentemente apoyado por la tomografía axial computarizada con contrastes. Se propone la utilización de estos criterios diagnósticos en Chile