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Official Journals By StatPerson Publication

Table of Content - Volume 9 Issue 2 - February 2019


Assessment of predicting factors for acute pancreatitis

 

MD Wahhaj1*, V S Prasad2, Mustahsan Ahmad Hashmi3

 

1Senior Resident, 2Associate Professor & HOD, 3Junior Resident, Department of Surgery. DMCH. Laheriasarai. Darbhanga, INDIA.

Email: drwahhaj@gmail.com

 

Abstract               Background: The incidence of acute pancreatitis varies in different centres and depends upon etiologic factors. Incidence of gallstone pancreatitis is more in this part of the world and males are affected more than females. This present study was undertaken to examine the clinical findings of acute pancreatitis and to look in particular at that group of patients who suffer life-threatening complications. Methods: 50 patients were admitted at Department of Surgery, DMCH, Laheriasarai, Darbhanga. During the period April 2016 to Feb 2017. This study comprised of 38 males and 12 females. The youngest patient was 22 years old and the eldest patient was 65 years old. The average age for total study group was 39.5 years. Postoperative cases of acute pancreatitis were not included within this study. Results: The mortality rate for acute pancreatitis was 12.0% Age, hypotension, tachycardia, fever, abdominal lump and abnormal lung findings correlated with increased morbidity and mortality. Leucocytosis was a common finding in patients with severe disease and was one of the most important parameters in prognosis. The other important abnormalities found are alteration in serum A.S.T. (SGOT) Amylase, Lipase L.D.H. L.D.H. in particular was found to be the most useful single marker of severe disease. High bilirubin was more pronounced in patients with gallstone etiology. Conclusion: The proper management of severe acute pancreatitis required understanding of its natural history and lots of patience. Laboratory markers may be useful to better quantify the severity of disease in patients with acute pancreatitis.

Key Word: acute pancreatitis, peripancreatic necrosis,

 

 

 

INTRODUCTION

The pancreas is divided into the head, neck, body and tail. The head is flattened and firmly fixed on the right to the second and third part of the duodenum. To the left it merges into the neck along an arbitrary line marked by the gastroduodenal artery above and superior mesenteric and portal vein behind. Its anterior surface is covered by the pylorus above and the transverse colon below. Together with the second part of the duodenum it is traversed by the attachment of the transverse mesocolon that may be quite short here. Full mobilization of the pancreatic head is incomplete without ‘taking down’ the hepatic flexure of the colon. There are no pathognomic symptoms and signs, but pain is usually the cardinal symptom. Pain may vary from mild and moderate discomfort to severe, constant and incapacitating distress. Characteristically, the pain, which is steady and boring in character, is located in the epigastrium and periumbilical region and often radiates to the back as well as to the chest, flanks and lower abdomen. Pain may be felt differently throughout the abdomen.  The pain is frequently more intense when the patient is supine, and patients often obtained relief by sitting with trunk flexed and knees drawn up. Nausea, vomiting and abdominal distension due to gastric and intestinal hypo -motility and chemical peritonitis are also frequent complaints. Vomiting is often frequent and persistent, and retching may persist despite the stomach being kept empty by nasogastric aspiration. Hiccoughs can be troublesome and may be due to gastric distension or irritation of the diaphragm by retroperitoneal inflammation tracking upwards from the inflamed pancreas. Most attack of acute pancreatitis are mild and settle promptly on conservative treatment.  However, approximately 25% cases are severe with a significant risk of progression to potentially lethal complications. Separation of patients into good ’and` bad’ prognostic groups on admission to hospital have three major advantages.1 Early clinical assessment of the severity or potential severity of acute pancreatitis is very much difficult.  Severe attacks are identified correctly at the time of admission by experienced clinicians in only 34-39% of patients;2,3 conversely, only 80% of attacks classed initially as mild prove to be uncomplicated.3 Obesity is an important prognostic factor, and large fat deposits in the peripancreatic and retroperitoneal spaces may increase the risk of peripancreatic necrosis, abscess formation and death. Of 19 patients with body mass index exceeding 30kg./height in m2 ­in one report from Cape Town, 12 developed severe disease, 7 have abscesses, and 7 died4 Porter & Banks in a series of 27 patients with severe pancreatitis in Boston found that Obesity was associated Patients with acute pancreatitis should be monitored closely for the development of organ failure. The international symposium in 1992 determined that organ failure was the most important indicator of severity of acute pancreatitis (Table 2). The prognosis for the patient is closely related to the number of organs that have failed5,6 Organ system failure complicates up to 92% of deaths.53and failure of more than one organ greatly increases the risk of death.5,6

 

METHODS

50 patients were admitted at Department of Surgery, DMCH, Laheriasarai, Darbhanga. During the period April 2016 to Feb 2017. This study comprised of 38 males and 12 females. The youngest patient was 22 years old and the eldest patient was 65 years old. The average age for total study group was 39.5 years. Postoperative cases of acute pancreatitis were not included within this study. A thorough physical examination was done. This included general survey, local and systemic examination. On analysis of the patient’s complaints and physical examination, a tentative diagnosis was made from the possible differential diagnosis. Various laboratory investigations, routine and special, were undertaken. These include routine examination of blood (Total and differential counts and Hb %); urine and stool. Biochemical studies were done in the department of Biochemistry in this institution and also from other laboratories. Blood sugar, blood urea, serum creatinine, serum albumin, serum bilirubin, serum lactic dehydrogenase (LDH), serum aspartate aminotransferase and serum calcium were estimated. Serum lipase was studied only in forty two cases. Serum amylase estimation was done as a routine procedure in all case of acute pancreatitis. Serum amylase study was done as a routine procedure in all emergent admission with acute abdomen like acute pancreatitis, peptic perforation, intestinal obstruction, colicky pain, and abdominal distension. Straight x-ray was also done for follow-up cases particularly those with abdominal lump like phlegmon or pseudocyst of pancreas. Straight x-ray of abdomen was done in the hospital in all emergent cases. X-ray chest was performed in all patients with acute pancreatitis to demonstrate any pulmonary pathology like, pleural effusion, basal atelectasis, and pulmonary oedema mainly of the left side. E. C. G. was done for moderate and severe attack i. e. in twenty patients Ultrasonography was done for fifty patients with acute pancreatitis and subsequently for detection of local complication e.g. phlegmon, pseudocyst or abscess.  C.T. Scan was done for selective cases (fifteen cases) as it is expensive and it was advised upon clinical diagnosis of peripancreatic fluid collection, pseudocyst, pancreatic necrosis, and pancreatic abscess.


 RESULTS

Table 1: Prognosis of Acute Pancreatitis in relation to Age and Sex.

Age

Sex

Mortality

(In year)

Male

Female

Male

Female

21 — 30

08

1

0

-

31 — 40

12

2

1

0

41 — 50

15

8

2

1

51 — 65

03

1

1

1

Total

38

12

4

2

 

Table 2: Relation to Etiological Factors

Etiological Factors

No. of Patients

Mortality

Alcoholism

33 (66%)

04 (08%)

Biliary tract disease

07 (14%)

01 (02%)

Idiopathic

09 (18%)

01 (02%)

Blunt Trauma

01 (2%)

00 (00%)

Total

50 (100%)

06 (12%)

Table 3: Prognostic Value of Laboratory Examination

Laboratory Feature

Significant Value

Admission and First Hospital Day

Admission and First 4th Hospital Day

Entire Hospital Course

White Blood Cell

> 15000/mm3

19 (38%)

09 (18%)

04 (8%)

Serum Amylase

750- >100 U/ L

50 (100%)

42 (84%)

10 (20%)

Serum Lipase

100 - > 400

U/ L

50 (100%)

43 (86%)

10 (20%)

Serum Bilirubin

> 3 mg /dl

12 (24%)

09 (18%)

04 (8%)

Serum LDH

> 350 i.u / L

14 (28%)

13 (26%)

09 (18%)

SGOT

> 250 u/L

18 (36%)

14 (28%)

04 (8%)

Serum Calcium

< 8 mg / dl

03 (06%)

03 (06%)

01 (2%)

Blood sugar

> 200 mg/dl

11 (22%)

08 (16%)

02 (4%)

 

Table 4: Mortality associated with complication

Complications

Total no. of Patients

Mortality rate

Respiratory Failure

3 (6%)

2 (4%)

Renal Failure

2 (4%)

1 (2%)

Pseudocyst

8 (16%)

2 (4%)

Pancreatic Abscess

1 (2%)

1 (2%)

DISCUSSION

Fifty patients were admitted Department of Surgery, DMCH, Laheriasarai, Darbhanga. During the period April 2016 to Feb 2017. The mortality rate for acute pancreatitis was 12%. Majority of patients analysed in this study had addiction to alcohol 66 %. Biliary tract disease was present in 14% of cases. 18% had neither history of alcoholism nor biliary tract disease i.e. idiopathic group and 2% had a history of blunt trauma. The mortality rate for the alcoholic group (08%) was higher than idiopathic group that of (2%) or that of biliary tract disease also (2%). Failure to make the diagnosis has important implications when attempting to define mortality rates and the statement that they continue to fall must be treated with caution. Thus the fall in mortality rates from 17.8% in 1961 to 5.8% in 1985 in Scotland7 has to be taken in conjunction with the fact that no less than 42% of patients dying from acute pancreatitis in Glasgow Royal Infirmary within this period had their disease diagnosed for the first time at autopsy.57 Similarly, 35% of the fatal cases in Bristol were diagnosed for the first time at autopsy, case mortality remaining at around 20% throughout the study.8,9 It is clear that we have no ground for complacency regarding our ability to diagnose and treat acute pancreatitis. Foster and Ziffren reported a high mortality of 86.9% in a group of 23 patients with acute pancreatitis and shock..10 Facey et al, Elliot and Ranson, all reported that, in most instances, hypotension did not present in the face of vigorous intravenous replacement. Marshall L. J. and Daggett reported greater than 39% mortality among the 33 patients who presented with a systolic blood pressure less than 90 mmHg. In this present series, there was 40% mortality among the 20 patients who presented with a systolic blood pressure of less than 90 mmHg, though the usual measures were taken to correct hypovolemia. Black reported fever as a presenting sign in 75% of the group of 250 patients with acute pancreatitis. Marshall L.J. and Daggett et al reported that 142 patients (27%) had an initial temperature greater than 101°F and 20% of these patients died.11 In the present series 23 patients (23.95%) had an initial temperature greater than 101°F and 30.45% of these patients died. The aforementioned studies do not selectively address the question of surgical treatment of those severely ill patients with acute pancreatitis who continue to deteriorate despite maximal medical treatment. These patients might benefit from any of several therapeutic modalities currently under evaluation. These included peritoneal lavage, subtotal pancreatectomy and the use of anti-enzyme preparation. Kivilaakso et al 1981 reported their experience of early surgery in 30 severely ill patients (mean age 37.4 years). Most of the operations were distal pancreatic resections and the overall mortality was 37%.12 This is comparable to the results in reports of conservatively managed patients. They subsequently compared early surgery (distal pancreatic resection) to peritoneal lavage performed through catheters placed around the pancreas at laparotomy (Kilvilaakso et al 1984).13 The mortality was less in the respected group (4 from 18, compared to 8 from 17 in the lavage group) although the number were small. The authors analysed the patients according to the extent of pancreatic damage. In general, the more extensive the damage the higher is the mortality. This early direct surgical intervention is seldom advocated in older patients but in younger severely ill patients, not responding to conservative management, it still has a place. No such trial was given in the present series. Only a small portion of all patients with pancreatitis have such severe disease and the experience quoted above is difficult to repeat.

 

CONCLUSION

In patients with severe disease, changes occurred in almost any of the major body systems. Biochemical and haematological abnormalities; renal, circulatory, and respiratory failure and sepsis in and around the pancreas have been found to be significant contributory factors to morbidity and mortality. No single parameter, clinical recording, biochemical or haematological test was found to be consistently accurate in its prognostic value. The proper management of severe acute pancreatitis required understanding of its natural history and lots of patience.

 

REFERENCES

  • Williamson RCN 1984 Early assessment of severity in acute pancreatitis. Gut 25:1331
  • McMahon MJ, Playforth MJ, Pickford IR 1980 A comparative study of methods for the prediction of severity of attacks of acute pancreatitis. BJS 67:22.
  • Corfield AP, Williamson RCN, McMahon MJ et al 1985 prediction of severity in acute pancreatitis: prospective comparison of three prognostic indices. Lancet ii: 403.
  •  Funnel IC, BornMan PC, Weakley SP, Terblanche J,Marks IN 1993 Obesity: an important prognostic factor in acute pancreatitis. BJS 80:484.
  • Banks PA,Tenner S, Noordhoek EL et al Does Pancreatic necrosis predict severity in patients with acute pancreatitis? Digestion 1996; 57:218
  • Livingstone DH,Deitch EA,Multiple organ failure; a common problem in Surgical intensive care unit patients .Ann.Med  1995;27:13-20
  • Wilson C, Imrie C W,1990 Changing pattern of incidence and mortality from acute pancreatitis in Scotland, 1961-1985.BJS 77:731
  • Wilson C, Imrie c w, Carter d c, 1988 Fatal acute pancreatitis.Gut 29:782
  • Corfield A P, Cooper M J, Williamson R C N, 1985 Acute pancreatitis: a lethal disease of increasing incidence. Gut 26: 724
  • Foster P D, Ziffren S E. Severe acute pancreatitis. Arch . Surg,1962.
  • Jacobs M L, Daggett W M, Civetta J M, et al Acute pancreatitis:Analysis of factors influencing survival. Annals of Surgery 185  43-51, 1977.
  • Kivilaakso E, Fraki O, Nikki P, Lenipinen M, 1981 Resection of         the    pancreas for acute fulminant pancreatitis Surgery Gynaecology Obstetrics 152: 493-8
  • Kivilaakso E , Lempinen M , Makelainen A , Nikki P , Schroder T , 1984 Pancreatic resection versus Peritoneal lavage for acute fulminant pancreatitis. Annals of Surgery 199: 426-31