Cuantificación de la concentración del iodo con TC de doble energía en pacientes con pancreatitis aguda / Quantification of iodine concentration by dual-energy CT in patients with acute pancreatitis

OBJETIVO: Determinar si existen diferencias en la concentración de iodo cuantificada con TC de doble energía en el páncreas de pacientes con pancreatitis aguda y pacientes sin signos analíticos ni en imagen de patología pancreática. MATERIAL Y MÉTODOS: Se estudian 27 casos de pancreatitis aguda a los que se realizó una TC con energía dual a las 48-72 horas del inicio de los síntomas, realizada con contraste intravenoso y una sola fase con un retraso de 55 segundos. Se compara con un grupo control de 11 pacientes con una TC realizada con el mismo protocolo, pero sin datos radiológicos de pancreatitis y amilasa y lipasa normales. Mediante posprocesado se obtienen reconstrucciones con mapa de iodo y se realizan tres regiones de interés en cabeza, cuerpo y cola pancreática para obtener los valores de concentración de iodo (mg/ml) y se comparan entre ambos grupos. Se hace un segundo cálculo normalizando la densidad de iodo con la aorta. RESULTADOS:En las pancreatitis, el valor medio de densidad de iodo es 2,5mg/ml. En el grupo de los controles es de 3,65mg/ml (p = 0,02). Hay tres casos con necrosis glandular en los que la densidad de iodo es 1,53mg/ml. CONCLUSIONES: Existen diferencias significativas en la concentración de iodo del páncreas medida en TC con energía dual entre pacientes con pancreatitis aguda en fases iniciales y pacientes sin signos analíticos ni en imagen de patología pancreática

OBJECTIVE: To determine whether pancreatic iodine concentrations quantified by dual-energy CT differ between patients with acute pancreatitis and those without imaging or laboratory findings indicative of pancreatic disease. MATERIAL AND METHODS: We compared findings on single-phase dual-energy CT images acquired 55seconds after the intravenous administration of contrast material in 27 patients with acute pancreatitis who underwent the examination 48 to 72hours after the onset of symptoms versus in 11 patients (controls) with no imaging findings suggestive of pancreatic disease and normal amylase and lipase who underwent the examination with the same protocol for other purposes. Imaging postprocessing included the generation of iodine maps. Three regions of interest were selected (pancreatic head, body, and tail) to obtain iodine concentrations (mg/ml) to compare between groups. Iodine concentrations were also calculated a second time by normalizing the density of iodine with the aorta. RESULTS: The mean density of iodine was 2.5mg/ml in patients with pancreatitis vs. 3.65mg/ml in controls (p = 0.02). In three patients with glandular necrosis, the density of iodine was 1.53mg/ml. CONCLUSIONS: The concentration of iodine in the pancreas measured with dual-energy CT differs significantly between patients with initial-stage acute pancreatitis and those without imaging or laboratory findings indicative of pancreatic disease

The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review.

Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.

Manejo actual de la pancreatitis aguda idiopática y la pancreatitis aguda recurrente / Current management of acute idiopathic pancreatitis and acute recurrent pancreatitis

La pancreatitis aguda es una entidad de notable importancia debido a su elevada incidencia y a su no desdeñable morbimortalidad. Se conoce como pancreatitis aguda idiopática aquella en la que no se consigue determinar la causa del cuadro tras un estudio básico inicial. Conocer la etiología subyacente permite plantear un tratamiento dirigido para así disminuir el riesgo de recurrencia. La ecoendoscopia y la colangiografía por resonancia magnética son las pruebas de elección para profundizar en el estudio etiológico. La principal causa es la enfermedad litiásica no diagnosticada en el estudio inicial, cuyo tratamiento de elección es la colecistectomía. Por otra parte, la pancreatitis aguda recurrente se diagnostica tras la existencia de 2 o más episodios de pancreatitis aguda. El objetivo de esta revisión es proporcionar una aproximación actualizada de estas 2 entidades, repasando aspectos de su epidemiología, diagnóstico y alternativas terapéuticas disponibles

Acute pancreatitis is an entity of notable importance due to its high incidence and its non-negligible morbidity and mortality. Idiopathic acute pancreatitis is that in which the cause of the clinical condition cannot be determined after an initial basic study. Understanding the underlying aetiology enables clinicians to propose a targeted treatment to reduce the risk of recurrence. Endoscopic ultrasonography and magnetic resonance cholangiopancreatography are the tests of choice to deepen the aetiological study. The main cause is undiagnosed lithiasic disease in the initial study, whose treatment of choice is cholecystectomy. Moreover, recurrent acute pancreatitis is diagnosed after 2 or more episodes of acute pancreatitis. The objective of this review is to provide an updated approach for these 2 entities, reviewing aspects of their epidemiology, diagnosis and available alternative therapies

[Acute pancreatitis in intensive care medicine : Which risk score is useful?] / Akute Pankreatitis in der Intensivmedizin : Welcher Risikoscore ist hilfreich?

INTRODUCTION: Acute pancreatitis is a disease with an increasing incidence in the Western countries associated with a high mortality depending on severity of disease. Etiology is often biliary or due to alcoholism. Incidence of etiology varies between regions depending on risk-factor prevalence. Several risk scores are available to estimate mortality. The aim of the study is to identify the risk factors most relevant for patients being treated for severe acute pancreatitis in an ICU of a tertiary medical center. PATIENTS AND METHODS: The retrospective cohort study included 91 patients (61.2% men, mean age 52 years) with severe acute pancreatitis who were treated between 2002 and 2013 at the medical ICU of a tertiary medical center. Risk factors were identified using COX regression analysis and associations were assessed with the χ2 test. RESULTS: Pulmonary failure necessitating ventilator support, renal failure requiring renal replacement therapy, need for vasopressor therapy, positive blood cultures, and bleeding complications were identified as risk factors for high mortality in severe acute pancreatitis. Low calcium and high lactate levels are independent risk factors for mortality. CONCLUSION: Critically ill patients with severe pancreatitis have high mortality rates that can be estimated using risk scores. Weighting of risk factors may differ depending on region and severity of disease. For patients included in our study, the Ranson Criteria and the APACHE II Score may be most applicable.

Predictors and outcomes of moderately severe acute pancreatitis - Evidence to reclassify.

BACKGROUND/OBJECTIVES: After the creation of the moderately severe acute pancreatitis (MSAP) category in the Revised Atlanta Classification in 2012, predictors to identify these patients early have not been identified. The MSAP category includes patients with (peri)pancreatic necrosis, fluid collections, and transient organ failure in the same category. However, these outcomes have not been studied to determine whether they result in similar outcomes to merit inclusion in the same severity. METHODS: Retrospective, review of 514 consecutive, direct admissions for acute pancreatitis from 2010 to 2013. Multivariate logistic regression identified predictors of MSAP. RESULTS: Persistent SIRS was the best prognostic marker of MSAP with AUC 0.72. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for persistent SIRS to predict MSAP are: 55%, 88%, 40%, 93%, and 84%. Patients with necrosis had significantly longer length of stay (LOS) (p = 0.0001) and higher rates of ICU admission (p = 0.02) compared with patients with transient organ failure. Compared to those with acute fluid collections, patients with necrosis had longer LOS (p < 0.0001), higher rates of ICU admission (p = 0.0005), required more interventions (p = 0.001), and demonstrated higher mortality (0.003). DISCUSSION: Moderately severe pancreatitis can be distinguished from mild pancreatitis on the basis of persistent SIRS but cannot be accurately distinguished from severe pancreatitis in the first 48 h (Peri)pancreatic necrosis demonstrates significantly more morbidity compared to the other components of MSAP of fluid collections and transient organ failure.

Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis - An international multicenter evaluation of the revised Atlanta classification.

BACKGROUND: For consistent reporting and better comparison of data in research the revised Atlanta classification (RAC) proposes new computed tomography (CT) criteria to describe the morphology of acute pancreatitis (AP). The aim of this study was to analyse the interobserver agreement among radiologists in evaluating CT morphology by using the new RAC criteria in patients with AP. METHODS: Patients with a first episode of AP who obtained a CT were identified and consecutively enrolled at six European centres backwards from January 2013 to January 2012. A local radiologist at each center and a central expert radiologist scored the CTs separately using the RAC criteria. Center dependent and independent interobserver agreement was determined using Kappa statistics. RESULTS: In total, 285 patients with 388 CTs were included. For most CT criteria, interobserver agreement was moderate to substantial. In four categories, the center independent kappa values were fair: extrapancreatic necrosis (EXPN) (0.326), type of pancreatitis (0.370), characteristics of collections (0.408), and appropriate term of collections (0.356). The fair kappa values relate to discrepancies in the identification of extrapancreatic necrotic material. The local radiologists diagnosed EXPN (33% versus 59%, P < 0.0001) and non-homogeneous collections (35% versus 66%, P < 0.0001) significantly less frequent than the central expert. Cases read by the central expert showed superior correlation with clinical outcome. CONCLUSION: Diagnosis of EXPN and recognition of non-homogeneous collections show only fair agreement potentially resulting in inconsistent reporting of morphologic findings.

Extra-pancreatic necrosis alone: Contours of an emerging entity.

Acute pancreatitis is of two morphologic types: interstitial edematous pancreatitis that is not associated with any tissue necrosis and necrotizing pancreatitis wherein the pancreatic parenchyma with or without varying amount of extra-pancreatic tissue/fat undergoes necrosis. Necrotizing pancreatitis has a worse outcome compared with interstitial pancreatitis because of increased severity related to a heightened systemic response and cytokine storm associated with tissue necrosis. Increasingly, an entity of extra-pancreatic necrosis (EPN) alone, wherein the pancreatic parenchyma is normal on an enhanced computed tomographic scan but the peri-pancreatic tissues undergo necrosis, is being recognized. Available data suggest that the outcomes in patients with EPN alone are between the excellent prognosis of patients with interstitial and adverse prognosis of patients with necrotizing pancreatitis. The extent of EPN also seems to determine the outcome. This review summarizes the currently available literature on this entity and various radiological scores that have been suggested to determine the presence and stage of EPN.

Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis.

BACKGROUND: Severity classification systems aim to stratify patients with acute pancreatitis reliably into coherent risk groups. Recently, the Atlanta 1992 classification has been revised (Atlanta 2012) and a novel determinant-based classification (DBC) system developed. This study assessed the ability of the three systems to stratify disease severity among patients with acute pancreatitis. METHODS: This was an observational cohort study of patients with acute pancreatitis identified from an institutional database. Cohort characteristics, investigations, interventions and outcomes were identified. Systems were compared using receiver operating characteristic (ROC) analysis and Spearman's correlation coefficients. RESULTS: The in-hospital mortality rate was 6·6 per cent (15 of 228 patients). All of the outcomes considered correlated significantly with the three systems, with the exception of the need for surgery in Atlanta 1992. Atlanta 2012 and the DBC had higher area under the curve (AUC) values than Atlanta 1992 for all outcomes. The revised Atlanta and DBC systems both performed similarly with regard to ICU admission (AUC 0·927 and 0·917 respectively; both P < 0·001), need for percutaneous drainage (AUC 0·879 and 0·891; both P < 0·001), need for surgery (AUC 0·827 and 0·845; P = 0·006 and P = 0·004 respectively) and in-hospital mortality (0·955 and 0·931; both P < 0·001). However, the critical category in the DBC system identified patients with the most severe disease; seven of eight patients in this group died in hospital, compared with 15 of 34 with severe pancreatitis according to Atlanta 2012. CONCLUSION: The Atlanta 2012 and DBC perform equally well for classification of disease severity in acute pancreatitis. The addition of a critical category in the DBC identifies patients with the most severe disease.

Necrotizing pancreatitis: A review of the interventions.

Acute pancreatitis may have a wide range of severity, from a clinically self-limiting to a quickly fatal course. Necrotizing pancreatitis (NP) is the most dreadful evolution associated to a poor prognosis: mortality is approximately 15% and up to 30-39% in case of infected necrosis, which is the major cause of death. Intervention is generally required for infected pancreatic necrosis and less commonly in patients with sterile necrosis who are symptomatic (gastric or duodenal outlet or biliary obstruction). Traditionally the most widely used approach to infected necrosis has been open surgical necrosectomy, but it is burdened by high morbidity (34-95%) and mortality (11-39%) rates. In the last two decades the treatment of NP has significantly evolved from open surgery towards minimally invasive techniques (percutaneous catheter drainage, per-oral endoscopic, laparoscopy and rigid retroperitoneal videoscopy). The objective of this review is to summarize the current state of the art of the management of NP and to clarify some aspects about its diagnosis and treatment.

Reduced lymphocyte count as an early marker for predicting infected pancreatic necrosis.

BACKGROUND: Early occurrence of immunosuppression is a risk factor for infected pancreatic necrosis (IPN) in the patients with acute pancreatitis (AP). However, current measures for the immune systems are too cumbersome and not widely available. Significantly decreased lymphocyte count has been shown in patients with severe but not mild type of AP. Whereas, the correlation between the absolute lymphocyte count and IPN is still unknown. We conduct this study to reveal the exact relationship between early lymphocyte count and the development of IPN in the population of AP patients. METHODS: One hundred and fifty-three patients with acute pancreatitis admitted to Jinling Hospital during the period of January 2012 to July 2014 were included in this retrospective study. The absolute lymphocyte count and other relevant parameters were measured on admission. The diagnosis of IPN was based on the definition of the revised Atlanta classification. RESULTS: Patients were divided into two groups according to the presence of IPN. Thirty patients developed infected necrotizing pancreatitis during the disease course. The absolute lymphocyte count in patients with IPN was significantly lower on admission (0.62 × 10(9)/L, interquartile range [IQR]: 0.46-0.87 × 10(9)/L vs. 0.91 × 10(9)/L, IQR: 0.72-1.27 × 10(9)/L, p < 0.001) and throughout the whole clinical course than those without IPN. Logistic regression indicated that reduced lymphocyte count was an independent risk factor for IPN. The optimal cut-offs from ROC curve was 0.66 × 10(9)/L giving sensitivity of 83.7 % and specificity of 66.7 %. CONCLUSIONS: Reduced lymphocyte count within 48 h of AP onset is significantly and independently associated with the development of IPN.

Necrotizing pancreatitis: diagnosis, imaging, and intervention.

Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.

Clinical relevance of the revised Atlanta classification focusing on severity stratification system.

BACKGROUND/OBJECTIVE: Recognizing the limitation of the Atlanta classification for acute pancreatitis (AP), two international classifications have been recently proposed; the revised Atlanta classification and the determinant-based classification. There is an inconsistency between the two international classifications on whether infected necrosis (IN) is the major determinant of severity in AP. The aim of the current study was to validate the revised Atlanta classification and to determine the association of this new classification system with relevant clinical outcome in patients with AP. METHODS: Data have been collected on 553 patients with AP admitted to a single center during the 7-year period commencing January 2006. Primary outcomes included the need for interventions, the need for intensive care unit (ICU) care, length of ICU stay, total hospital stay, and mortality. RESULTS: The different grades of severity for revised Atlanta classification system were associated with statistically significant differences in terms of clinical outcomes. Patients with severe AP that had IN, compared to those without IN, were associated with worse clinical outcomes. Having stratified patients with severe AP category according to the presence or absence of IN, the mortality rate increased fourfold to 32.3% for the presence of infected necrosis. CONCLUSIONS: Overall, the revised Atlanta classification seems to be valid, since it correlates well with clinical outcome. To more accurately assess clinical outcome of patients with severe AP defined by the revised Atlanta classification, however, severe AP patients with IN should be considered separately from those without IN in classification system.

Validation of the moderate severity category of acute pancreatitis defined by determinant-based classification.

BACKGROUND: Recent international multidisciplinary consultation proposed the use of local (sterile or infected pancreatic necrosis) and/or systemic determinants (organ failure) in the stratification of acute pancreatitis. The present study was to validate the moderate severity category by international multidisciplinary consultation definitions. METHODS: Ninety-two consecutive patients with severe acute pancreatitis (according to the 1992 Atlanta classification) were classified into (i) moderate acute pancreatitis group with the presence of sterile (peri-) pancreatic necrosis and/or transient organ failure; and (ii) severe/critical acute pancreatitis group with the presence of sterile or infected pancreatic necrosis and/or persistent organ failure. Demographic and clinical outcomes were compared between the two groups. RESULTS: Compared with the severe/critical group (n=59), the moderate group (n=33) had lower clinical and computerized tomographic scores (both P<0.05). They also had a lower incidence of pancreatic necrosis (45.5% vs 71.2%, P=0.015), infection (9.1% vs 37.3%, P=0.004), ICU admission (0% vs 27.1%, P=0.001), and shorter hospital stay (15+/-5 vs 27+/-12 days; P<0.001). A subgroup analysis showed that the moderate group also had significantly lower ICU admission rates, shorter hospital stay and lower rate of infection compared with the severe group (n=51). No patients died in the moderate group but 7 patients died in the severe/critical group (4 for severe group). CONCLUSIONS: Our data suggest that the definition of moderate acute pancreatitis, as suggested by the international multidisciplinary consultation as sterile (peri-) pancreatic necrosis and/or transient organ failure, is an accurate category of acute pancreatitis.

Clasificación Internacional y Multidisciplinaria de la Pancreatitis Aguda: Edición española 2013 / International Multidisciplinary Classification of Acute Pancreatitis Severity: The 2013 Spanish Edition

OBJETIVO: Desarrollar una nueva clasificación de la gravedad de la pancreatitis aguda sobre la base de un sólido marco conceptual, la revisión exhaustiva de la evidencia publicada, y una consulta en todo el mundo. ANTECEDENTES: Las definiciones Atlanta'92 de la gravedad de la pancreatitis aguda están muy arraigadas entre los pancreatólogos, pero con un resultado deficiente debido a que estas definiciones están basadas en la descripción empírica de hechos que no están asociadas con la gravedad. MÉTODOS: Se envió una invitación personal para contribuir al desarrollo de una nueva clasificación de la gravedad de la pancreatitis aguda a todos los cirujanos, gastroenterólogos, internistas, intensivistas, radiólogos y que actualmente se encuentran activos en el campo de la pancreatitis aguda. La invitación no se limitó a los miembros de determinadas asociaciones o residentes de ciertos países. Se llevó a cabo una encuesta basada en una web mundial y se organizó un simposio internacional para que los colaboradores de las diferentes disciplinas se dedicaran a debatir el concepto y definiciones. RESULTADOS: La nueva clasificación se basa en los determinantes reales locales y sistémicos de gravedad, en lugar de la descripción de los eventos que están asociados con la causa de la gravedad. El factor determinante local se refiere a si existe necrosis (peri) pancreática o no, y si está presente, si es estéril o infectado. El factor determinante sistémico se refiere a si existe fracaso orgánico o no, y si está presente, ya sea de forma transitoria o persistente. La presenciade un determinante puede modificar el efecto de otra, de tal manera que la presencia tanto de la necrosis (peri) pancreática infectada y el fracaso orgánico persistente tienen un mayor efecto sobre la gravedad que si esas determinantes son únicas. La clasificación basada en los resultados de los principios anteriores deriva en 4 categorías de gravedad: leve, moderada, severa y crítica. CONCLUSIONES: Esta clasificación es el resultado de un proceso de consulta entre pancreatólogos de 49 países que abarcan América del Norte, América del Sur, Europa, Asia, Oceanía y África. Ofrece una puesta al día de un conjunto de definiciones concisas, de todas las principales entidades necesarias para clasificar la gravedad de la pancreatitis aguda durante la práctica clínica y para su uso en la investigación. Esto asegura que en todo el mundo se pueda utilizar uniformemente la clasificación basada en factores determinantes

OBJECTIVE: To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and world wide consultation. Backgrounds: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity. METHODS: A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global webbased survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. RESULTS: The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical. CONCLUSIONS: This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world

[Multidisciplinar international classification of the severity of acute pancreatitis: Italian version 2013]. / Classificazione Internazionale Multidisciplinare della Gravità della Pancreatite Acuta Versione Italiana 2013.

AIM: The aim of this paper was to present the 2013 Italian edition of a new international classification of acute pancreatitis severity. The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity. METHODS: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. A global web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. RESULTS: The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical. CONCLUSION: This classification provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.

Clinical importance of the determinant-based classification of acute pancreatitis severity.

PURPOSE: This classification should eliminate the confusion in terminology occurring over the last 20 years with direct implications in clinical practice. METHOD: The study was based on the web-based consultation of experts worldwide. 528 invitations were sent and 240 responses received from 49 countries from all continents. RESULTS: In an attempt to eliminate many confusions of the old classification, definitions that have built-in modern concepts of the disease have been issued, clinical evaluation of these severity has been improved and a standardized reporting data to objectively evaluate new treatments and to facilitate the communication of data between centers has been created. DISCUSSIONS: An ideal classification should reflect the whole area of clinical and paraclinical changes for one patient, at a given time. In the chosen classification, the main variable that characterizes the degree of severity is only the transitory or persistent organ dysfunction(s) failure(s). CONCLUSIONS: The most significant contribution to this update is redefining local complications based on their content,existence or non-existence of the wall, the place of their appearance and their evolution over time (local determinants).Systemic determinants take into account the presence of organ failures (transient or persistent). The presence of determinant factors has a cumulative effect.

The new revised classification of acute pancreatitis 2012.

This study aims to update the 1991 Atlanta Classification of acute pancreatitis, to standardize the reporting of and terminology of the disease and its complications. Important features of this classification have incorporated new insights into the disease learned over the last 20 years, including the recognition that acute pancreatitis and its complications involve a dynamic process involving two phases, early and late. The accurate and consistent description of acute pancreatitis will help to improve the stratification and reporting of new methods of care of acute pancreatitis across different practices, geographic areas, and countries.

Assessment of the severity of acute pancreatitis by contrast-enhanced computerized tomography in 350 patients.

BACKGROUND: This prospective study has been conducted with the aim to assess the severity of acute pancreatitis. METHODS: The study included 350 consecutive patients with acute pancreatitis admitted over a period of five years. All these patients were subjected to detailed history and clinical examination and investigations to ascertain the diagnosis. The severity was assessed by contrast - enhanced computed tomography (CT). Data collected were tabulated and subjected to appropriate statistical analysis. RESULTS: On the basis of the CT Severity Index (CTSI), the severity of acute pancreatic was classified into Group A (mild), Group B (moderate), or Group C (severe). Group C patients had the most complications (in 77 [91.67%] patients), and Group A patients had the least (in 7 [6.25%] patients). Mortality was found to be highest among Group C (14 [16.67%] patients), indicating the severe nature of disease in these patients, while no mortality was noted in Group A patients. The mean duration of hospital stay of patients in Group A was 9.25 days, Group B 12.0 days and Group C 24.58 days. CONCLUSION: The use of contrast-enhanced computed tomography as a routine investigation in patients to predict a severe attack of acute pancreatitis early in the course of the disease decreases overall mortality and burden of disease.

Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis?

OBJECTIVE: In the revised Atlanta classification of acute pancreatitis, the term necrotising pancreatitis also refers to patients with only extrapancreatic fat necrosis without pancreatic parenchymal necrosis (EXPN), as determined on contrast-enhanced CT (CECT). Patients with EXPN are thought to have a better clinical outcome, although robust data are lacking. METHODS: A post hoc analysis was performed of a prospective multicentre database including 639 patients with necrotising pancreatitis on contrast-enhanced CT. All CECT scans were reviewed by a single radiologist blinded to the clinical outcome. Patients with EXPN were compared with patients with pancreatic parenchymal necrosis (with or without extrapancreatic necrosis). Outcomes were persistent organ failure, need for intervention and mortality. A predefined subgroup analysis was performed on patients who developed infected necrosis. RESULTS: 315 patients with EXPN were compared with 324 patients with pancreatic parenchymal necrosis. Patients with EXPN less often suffered from complications: persistent organ failure (21% vs 45%, p<0.001), persistent multiple organ failure (15% vs 36%, p<0.001), infected necrosis (16% vs 47%, p<0.001), intervention (18% vs 57%, p<0.001) and mortality (9% vs 20%, p<0.001). When infection of extrapancreatic necrosis developed, outcomes between groups were equal (mortality with infected necrosis: EXPN 28% vs pancreatic necrosis 18%, p=0.16). CONCLUSION: EXPN causes fewer complications than pancreatic parenchymal necrosis. It should therefore be considered a separate entity in acute pancreatitis. Outcome in cases of infected necrosis is similar.

[Diagnosis, follow-up, and treatment policy making in patients with acute pancreatitis (CT and MRI evidence)].

The paper deals with the use of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis, followup, and treatment policy making in patients with severe acute severe pancreatitis with manifestations as pancreatic necrosis, fluid collections (exudate accumulations in peripancreatic and retroperitoneal spaces), as well as that complicated by infection, abscess, and pseudocysts. The results of examining 502 patients with acute pancreatitis (AP) with different complications, who had been treated at the S.P. Botkin City Clinical Hospital in 2007 to 2010, were used to analyze the data of the study, to detail tactics in the diagnosis and follow-up of patients with AP, by using bolus contrast-enhanced CT in combination with MRI, which allows one to reveal the nature and severity of the disease with a high accuracy, to make its prognosis, and to determine the effective procedure of treatment. Substantiation of the imperfection of the 1992 Atlanta classification and its specifying Balthazar classification figures high in the paper.