Introduction

Acute pancreatitis (AP) carries an overall mortality rate of 4.2%, but in cases of severe acute pancreatitis (SAP), mortality dramatically increases to over 50%. Despite the use of several scoring systems to predict SAP in the early stages of the disease, their clinical value is limited as their performance does not significantly influence decision-making due to their low post-test probability. Although early prediction upon admission would be ideal, the development of a marker that accurately predicts severity at this stage seems unlikely. Therefore, a dynamic assessment based on early identification of changes in clinical and laboratory parameters within the first 48 hours could prove valuable in detecting unfavorable outcomes.

Aims & Methods

The aim of our study was to evaluate the clinical utility of changes in routine clinical and laboratory parameters within the first 48 hours of admission in a Spanish cohort, based on likelihood ratios and post-test probability of severe acute pancreatitis (SAP). Patients admitted to our tertiary hospital with a diagnosis of acute pancreatitis were included. Demographic information, comorbidities, and the Bedside Index for Severity in Acute Pancreatitis (BISAP) score were collected upon admission, while vital signs, routine laboratory parameters typically used in acute pancreatitis, and the Systemic Inflammatory Response Syndrome (SIRS) criteria were collected upon admission and after 48 hours. Patients were followed until death or discharge and categorized into mild to moderately severe and severe acute pancreatitis groups.

Results

227 patients were included in the study. The mean age was 65.3 years (standard deviation 18.9), and 115 patients were women (50.7%). Among them, 22 (10.7%) developed severe acute pancreatitis, and 13 (5.7%) died. BISAP≥2, rising BUN, increasing heart rate over 20 beats per minute, and persistent SIRS were identified as independent risk factors for severe acute pancreatitis. The positive likelihood ratio and post-test probability of SAP are shown in Table 1. When combining the parameters independently related to SAP, we found that BISAP ≥2 combined with persistent SIRS after 48 hours and any rise in BUN combined with persistent SIRS showed the highest post-test probabilities (82% and 80%, respectively).

Predictor	+ LR (CI 95%)	+ Post-test probability of SAP
Rise in heart rate > 20 bpm	3.27 (1.44-7.43)	26% (13-44%)
Rising BUN	3.57 (2.52- 5.04)	28% (21-35%)
Rising Hematocrit	1.59 (0.75-3.36)	15% (8-28%)
BISAP ≥ 2	2.81 (2.16-3.66)	23% (19-28%)
SIRS on admission	2.80 (1.74-4.48)	23% (16-32%)
SIRS after 48h	12 (5.11-26)	56% (36-74%)
BISAP ≥ 2 and rising BUN	8.22 (4.80-14)	47% (34-60%)
BISAP ≥ 2 and SIRS after 48h	42 (9.62-181)	82% (51-95%)

Table 1. Positive likelihood ratio of clinical and laboratory parameters related to SAP with a pre-test probability of 10.7%.

Conclusion

Monitoring the evolution of the disease in the first hours is crucial, especially in patients who develop organ failure. For those who do not, dynamic assessment of known risk factors for SAP can be valuable in clinical practice. In our sample, the combination of BISAP and dynamic assessment of BUN, heart rate, and SIRS raised the probability of SAP up to 80%. Ideally, assessing the specific incidence of SAP in multicenter cohorts within a specific area and the impact of these and other factors that aid in monitoring patient evolution would provide valuable insights.

Introduction

Early identification of severe acute pancreatitis (SAP) enables the prompt initiation of aggressive resuscitation strategies and improves patient outcomes. The aim of the present study is to assess the clinical differences between patients with SAP and those with mild or moderate acute pancreatitis, as well as the distribution of organ failure in severe cases.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis, consecutively included from March 2017 to June 2019 at a tertiary care hospital. All included patients underwent systematic blood testing at admission and at 48 hours. Clinical management adhered to current clinical practice guidelines. Diagnosis and classification were based on the revised 2012 Atlanta classification. The analysis included the need for antibiotic therapy, development of local complications, organ failure patterns, and infectious complications

Results

	Mild/Moderately severe AP (n = 399 / 90.7%)	Severe AP (n = 41 / 9.3%)	p-value
Necrotizing pancreatitis	8 (2.1%)	13 (34.2%)	0.001 **
Infected necrosis	4 (1%)	6 (16.2%)	0.001 **
Antibiotic therapy	129 (32.9%)	29 (74.4%)	0.001 **
Extrapancreatic infection	35 (12.5%)	10 (28.6%)	0.011 **
Mortality	2 (0.5%)	18 (43.9%)	0.001 **
Cholangitis	145 (36.3%)	18 (43.9%)	0.340
ICU admission	3 (0.3%)	12 (29.3%)	0.001 **
SIRS at admission	56 (14.1%)	26 (63.4%)	0.001 **
SIRS at 48 hours	17 (4.3%)	22 (55%)	0.001 **

Table 1 summarizes the clinical characteristics and outcomes associated with severe acute pancreatitis (SAP). Regarding infectious complications, patients with SAP showed higher rates of infected necrosis and extrapancreatic infections, although no significant differences were observed in the incidence of acute cholangitis. Patients with SAP were more likely to develop necrotizing pancreatitis and local complications. Moreover, they accounted for the vast majority of ICU admissions and deaths. In terms of persistent organ failure, renal failure was the most frequent (80%), followed by respiratory failure (45%). A high proportion of patients who developed SAP presented with SIRS at admission (64%) and at 48 hours (55%).

Conclusion

Early identification of severe acute pancreatitis (SAP) is not always straightforward and requires close monitoring. Nevertheless, recognizing these patients is critical, as prognosis is intrinsically linked to the timeliness of diagnosis and the implementation of supportive measures necessary to maintain organ stability.
Patients with SAP are at higher risk of developing organ failure. In our cohort, we observed increased use of antibiotic therapy among SAP patients, likely due to the higher incidence of infected necrosis and extrapancreatic infections. Conversely, the incidence of acute cholangitis, based on the 2018 Tokyo criteria, was similar between SAP and mild/moderate AP cases.
Regarding organ failure, renal failure was the most frequent in our cohort, although other series have reported respiratory failure as the most common. The presence of SIRS at admission and at 48 hours was associated with subsequent development of SAP; however, a significant number of patients with SIRS did not ultimately develop a severe course. Its predictive value may be enhanced when combined with other prognostic factors.

References

1. Banks, P. A., Bollen, T. L., Dervenis, C., Gooszen, H. G., Johnson, C. D., Sarr, M. G., Tsiotos, G. G., & Vege, S. S. (2013). Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut, 62(1), 102–111.
2. Garg, P. K., & Singh, V. P. (2019). Organ Failure Due to Systemic Injury in Acute Pancreatitis. Gastroenterology, 156(7), 2008–2023.
3. Pezzilli, R., Zerbi, A., Campra, D., Capurso, G., Golfieri, R., Arcidiacono, P. G., Billi, P., Butturini, G., Calculli, L., Cannizzaro, R., Carrara, S., Crippa, S., De Gaudio, R., De Rai, P., Frulloni, L., Mazza, E., Mutignani, M., Pagano, N., Rabitti, P., & Balzano, G. (2015). Consensus guidelines on severe acute pancreatitis. Digestive and Liver Disease, 47(7), 532–543

Introduction

Acute pancreatitis (AP) is one of the most common diseases leading to admission in Gastroenterology departments. The aging population is contributing to an increasing number of hospitalizations among elderly patients. Our study aims to evaluate different clinical outcomes in patients across different age groups.

Aims & Methods

A retrospective analysis was conducted using a prospective database consisting of a cohort of patients with AP consecutively enrolled from March 2017 to June 2019 at a tertiary care hospital. Clinical management followed standard clinical practice guidelines, including routine abdominal ultrasound upon admission and CT scans in cases of diagnostic uncertainty or clinical deterioration. Diagnosis and classification were based on the revised 2012 Atlanta classification. Patients were divided into three age groups: <50 years, 50–75 years, and >75 years. Initially, a univariate analysis using the chi-square test was performed, followed by binary logistic regression to assess the influence of age on different clinical aspects of the disease.

Results

465 patients with AP were recruited. Overall, 48.6% of the patients were women; however, in the >75 age group, up to 64% were female. Older patients presented with more comorbidities, a greater need for antibiotic therapy, higher rates of severe AP, and an increased likelihood of mortality. These associations were confirmed in the multivariate analysis. Notably, patients over 75 years old had a higher risk of requiring antibiotic therapy (OR 2.73) and death (OR 7.42), while those aged 50–75 years had a higher risk of developing severe AP compared to younger patients (OR 8.05). No significant differences were found between age groups regarding the occurrence of necrotizing pancreatitis.

Table 1. Binary logistic regression analysis showing the increased risk of each variable by age group, using the youngest group (< 50 years old) as the reference category.

Age group	<50 (reference)	50-75 (OR: CI 95%)	p	>75 (OR: CI 95%)	p
Female sex	-	1.10 (0.66-1.82)	n.s	2.96 (1.77-4.96)	< 0.001
Necrotizing pancreatitis	-	0.76 (0.26-2.22)	n.s	0.62 (0.20-1.90)	n.s
Antibiotic use	-	1.33 (0.76-2.33)	n.s	2.73 (1.58-4.74)	<0.001
Severe acute pancreatitis	-	8.05 (1.04-61.95)	0.04	16.29 (2.17-122.07)	0.007

Conclusion

Our study presents the distribution of epidemiological and clinical variables across different age groups (<50 years, 50–75 years, and >75 years). We found that women over 75 years had a higher risk of developing AP compared to men, which could be influenced by an increased prevalence of biliary etiology with advancing age. Interestingly, patients over 75 years required antibiotic therapy more frequently, although the rates of necrotizing pancreatitis did not differ between age groups. This may suggest a higher incidence of other types of infections in older patients. Notably, patients over 75 years accounted for 80% of the deaths in our cohort, while no clear increase in mortality risk was observed in the 50–75 age group compared to younger patients. Finally, the risk of severe AP increased progressively with age, peaking in patients over 75 years. In conclusion, female sex was predominant among patients over 75 years, who also showed a significantly higher risk of severe AP and mortality, as well as a greater need for antibiotic therapy.

Introduction

Infectious complications are a significant concern in Acute Pancreatitis (AP), contributing to increased morbidity and mortality. Antibiotics are crucial in their management and should be initiated when infection is suspected. However, their overuse can lead to complications and antimicrobial resistance.

Aims & Methods

The aim of this retrospective study is to evaluate antibiotic utilization in real-world practice within a Spanish cohort and identify clinical and laboratory factors associated with their use. Patients admitted to our tertiary center for acute pancreatitis were included. Clinical and laboratory parameters routinely used in acute pancreatitis were collected upon admission and after 48 hours. Any infections (mainly infected necrosis, acute cholangitis following Tokyo 2018 criteria, pneumonia, and urinary tract infections) were documented, and patients were followed until discharge or death. Poor outcomes, such as severe acute pancreatitis based on the Atlanta 2012 classification and death, were assessed in patients who received antibiotics and those who did not.

Results

211 patients were recruited from July 2017 to December 2017. 111 (52.6%) were women, and in 170 (61.8%) the etiology was biliary. Antibiotic therapy was used in 77 (36.5%) patients, 21 had severe acute pancreatitis (9.95%) and 11 died (5.21%). Comparison between patients to whom antibiotics were prescribed and those who did not are shown on Table 1. Variables included in the logistic regression were SIRS on admission, PCR > 150mg/dL after 48h, PCT >1 ng/ml on admission and BT> 3mg/dL on admission with the presence of SIRS and BT >3 mg/dl at admission proving to be significant in the end.

N (%)	No antibiotics 134 (63,5%)	Need of antibiotics 77 (36,5%)	P value
Leucocytes, mean (sd)	12.642 (5.317)	14.390 (5.536)	< 0,005
Procalcitonin > 1 ng/ml, n (%)	13 (11,6)	18 (26,5)	< 0.01
Total Bilirrubin , mean (sd)	1.68 (1.84)	2.74 (2.57)	0,001
C reactive protein after 48h, mean (sd)	128 (112)	173 (129)	0,022
Temperature (Celsius), mean (sd)	36,2 (0,5)	36,3 (0,607)	n.s
SIRS, n (%)	13 (9.7)	29 (37.6)	<0.001
Extrapancreatic infection, n (%)	4 (1,9)	25 (32.4)	<0.001
Severe Acute Pancreatitis, n (%)	6 (4.4)	15 (19)	0.001
Death, n (%)	2 (1.4)	9 (11.6)	0.001

Table 1. Patient Characteristics: Comparison between patients with Indicated antibiotic therapy and those without antibiotic therapy

Conclusion

Antibiotic therapy is routinely used in AP due to infected necrosis, acute cholangitis, or extrapancreatic infections. However, the early inflammatory response typical in AP makes it troublesome to distinguish whether sepsis is occurring due to an extrapancreatic infection, leading to potential overuse of antibiotics. In our sample, antibiotics were used in 36.5% of patients, and those developed SAP and death more often. Among clinical and laboratory factors related to antibiotic use, only total bilirubin >3mg/dL and the presence of SIRS on admission were independently related to the need for antibiotics. However, it is possible that some patients with SIRS and high bilirubin on admission do not truly require antibiotics, as these changes can also be due to AP. Although procalcitonin has been positioned as a potential marker of infection and can guide the need for antibiotics, future research could explore other factors to better select patients without overt infection for empiric antibiotic therapy.

Introduction

Infections in acute pancreatitis are associated with increased morbidity, mortality, and healthcare costs. Early diagnosis is essential to improve prognosis and reduce mortality. The aim of the present study is to evaluate the distribution of infectious complications according to the underlying etiology.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis, consecutively included between March 2017 and June 2019 at a tertiary care hospital. All patients underwent systematic blood testing at admission and at 48 hours. Clinical management adhered to standard clinical practice guidelines. Diagnosis and classification were based on the revised 2012 Atlanta classification. Infectious complications were analyzed in patients with biliary and alcohol-related acute pancreatitis.

Results

Variable	Overall (n = 526)	Biliary (n = 304)	Alcohol-related (n = 39)	p-value
Acute cholangitis (Tokyo-18)
Suspected and/or confirmed	173 (37.6%)	140 (53.8%)	8 (20.4%)	0.001 **
Confirmed cases only	49 (29.2%)	43 (30.7%)	0	0.059
Antibiotic therapy	165 (36.1%)	123 (41.3%)	9 (23.7%)	0.037 **
Extrapancreatic infections (Total)	48 (14.3%)	34 (15.2%)	3 (13%)	1.000
Pneumonia	16 (4.8%)	8 (2.6%)	1 (2.6%)	1.000
Urinary tract infection	28 (8.4%)	25 (8.2%)	1 (2.6%)	0.335
Phlebitis / Catheter-related infection	4 (1.2%)	1 (0.3%)	1 (2.6%)	0.215
Infected pancreatic necrosis	11 (2.4%)	6 (2.1%)	2 (5.3%)	0.230

The distribution of infectious complications occurring during hospitalization is shown in Table 1. Up to 53.8% of patients with biliary acute pancreatitis presented with acute cholangitis according to the Tokyo-18 criteria, whereas this occurred in only 20.4% of alcohol-related cases. All cases of cholangitis in the alcoholic pancreatitis group, as well as the majority of those in the biliary group, met only the criteria for suspected acute cholangitis (100% vs. 53.8%, respectively). Antibiotic therapy was used in 41.3% of biliary pancreatitis cases, with a statistically significant difference compared to alcohol-related pancreatitis (23.7%). No significant differences were observed in the rates of extrapancreatic infections between the two groups, occurring in 15.2% and 13% of biliary and alcohol-related cases, respectively.

Conclusion

Extrapancreatic infections play a key role in the clinical course of acute pancreatitis, particularly in moderate and severe cases. The most frequent sites of infection include the respiratory and urinary tracts, as well as bloodstream infections. These infections are associated with an increased risk of complications, prolonged hospital stays, and higher mortality.
The characteristics of infections vary according to the etiology of pancreatitis. In our cohort, biliary pancreatitis was significantly more often associated with acute cholangitis, which is consistent with the pathophysiology of biliary-origin pancreatitis. Among patients with alcohol-related pancreatitis, up to 20% met criteria for suspected cholangitis; however, none fulfilled the criteria for confirmed cholangitis. This may be explained by the presence of acute-phase reactants and transient cholestasis, potentially leading to the administration of unnecessary antibiotic therapy.
Although previous studies have reported higher rates of respiratory infections in alcohol-related acute pancreatitis, our data showed no significant differences in these infections—or in infectious complications overall—between the two etiologies.

References

1. Petrov, M. S., Shanbhag, S., Chakraborty, M., Phillips, A. R. J., & Windsor, J. A. (2010). Organ Failure and Infection of Pancreatic Necrosis as Determinants of Mortality in Patients With Acute Pancreatitis. Gastroenterology, 139(3), 813–820.
2. Siriwardena, A. K., Jegatheeswaran, S., Mason, J. M., Siriwardena, A. K., Jegatheeswaran, S., Mason, J. M., Baltatzis, M., Sheen, A. J., O’Reilly, D. A., Jamdar, S., Deshpande, R., De Liguori Carino, N., Satyadas, T., Qamruddin, A., Hayden, K., Parker, M. J., Butler, J., & McIntyre, B. (2022). A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. The Lancet Gastroenterology & Hepatology, 7(10), 913–921.
3. Valverde-López, F., Martínez-Cara, J. G., & Redondo-Cerezo, E. (2022). Pancreatitis aguda. Medicina Clínica, 158(11), 556–563.

Introduction

The available evidence on the epidemiology of acute pancreatitis (AP) is primarily based on older studies conducted in other countries, limiting its applicability to local settings. This study aims to provide updated data on the clinical characteristics and outcomes of patients with AP in our region thereby improving understanding and management of the disease.

Aims & Methods

A retrospective analysis was conducted on a prospective database comprising a cohort of 526 patients with acute pancreatitis (AP), consecutively included between March 2017 and June 2019 at a tertiary care hospital. Systematic laboratory testing was performed at admission and again at 48 hours. Clinical management followed standard practice guidelines, including routine abdominal ultrasound after admission and abdominal CT scan in cases of diagnostic uncertainty, clinical deterioration, or lack of improvement. Diagnosis and classification were based on the revised 2012 Atlanta classification.

Results

The most frequent etiology of AP in our setting was biliary lithiasis (65.9%), followed by idiopathic (15.4%) and alcohol-related causes (8.4%). Severe AP accounted for 9% of cases, while 14.3% were classified as moderately severe. Up to 20.2% of patients developed local complications; however, only 4.9% presented with pancreatic necrosis. SIRS was observed in 18.7% of patients at admission, decreasing to 8.7% at 48 hours. Only 3.7% of patients required ICU admission (Table 1). Factors such as smoking, ERCP, antibiotic therapy, acute cholangitis, and SIRS showed significant differences across different etiological groups.

	Biliary	Alcohol	Hypertriglyceridemia	Pot-ERCP	Idiopathic	Total
Frequency	304 (65.9%)	39 (8.5%)	8 (1.7%)	5 (1.1%)	71 (15.4%)	461
Severe pancreatitis	28 (9.2%)	2 (5.1%)	0	1 (20%)	8 (12.7%)	42 (9%)
Local complications	24 (7.9%	6 (15.4%)	2 (25%)	1 (20%)	11 (15.5%)	106 (20.2%)
Transient organ failure (<48h)	46 (16.2%)	3 (8.1%)	2 (28.6%)	1 (20%)	14 (20.3%)	72 (16.3%)
Persistent organ failure (>48h)	28 (9.2%)	3 (7.7%)	0	0	9 (12.7%)	42 (9%)
SIRS at admission	46 (15.2%)	12 (30.8%)	1 (12.5%)	1 (20%)	16 (22.5%)	86 (18.5%)
Acute cholangitis (suspected and/or confirmed)	138 (45.5%)	7 (15.4%)	0	3 (60%)	17 (23.9%)	173 (37.6%)
Antibiotic therapy	123 (41.3%)	9 (23.7%)	1 (12.5%)	4 (80%)	19 (27.1%)	165 (36.1%)
ERCP performed	42 (14.1%)	0	0	2 (40%)	2 (2.9%)	49 (10.9%)

Conclusion

Acute pancreatitis (AP) is a common condition that imposes a significant healthcare burden. Determining the etiology of AP at admission is important not only from an epidemiological standpoint but also due to its profound implications for patient prognosis.
Contrary to what has been reported in the literature, the second most frequent cause of AP in our cohort was idiopathic, surpassing alcohol-related cases. In line with other studies, we observed significant differences between biliary and alcohol-related etiologies regarding smoking habits, development of acute cholangitis, need for ERCP, and use of antibiotic therapy. Patients with alcohol-related AP were significantly more likely to present with SIRS at admission. However, we did not find statistically significant differences in other key clinical outcomes, although patients with alcohol-related AP appeared to have a higher, but not statistically significant, risk of developing local complications, pancreatic necrosis, and SIRS at 48 hours.
This study highlights the importance of tailoring management strategies according to etiology to optimize clinical outcomes.

References

1. Wang, G. J., Gao, C. F., Wei, D., Wang, C., & Ding, S. Q. (2009). Acute pancreatitis: etiology and common pathogenesis. World journal of gastroenterology, 15(12), 1427–1430.
2. Petrov, M. S., & Yadav, D. (2019). Global epidemiology and holistic prevention of pancreatitis. Nature reviews. Gastroenterology & hepatology, 16(3), 175–184.
3. Iannuzzi, J. P., King, J. A., Leong, J. H., Quan, J., Windsor, J. W., Tanyingoh, D., Coward, S., Forbes, N., Heitman, S. J., Shaheen, A. A., Swain, M., Buie, M., Underwood, F. E., & Kaplan, G. G. (2022). Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology, 162(1), 122–134.