AN UPDATE ON ACUTE PANCREATITIS 11.01.2017

2. DR. ADITI AICH
(Internee Malda Medical College
and Hospital)

3.  Why speak of a classification
 Revised atlanta classification
 Need of severity stratification
 Different stratification systems
 What about Paediatric age group
 Recommendation

4. -Early assessment and accurate prediction
- Wide spectrum of the disease
- Care of patients is highly individualised
- Difference of treatment protocol on basis of
severity
- Difference of treatment protocol in different
set ups.

5. Atlanta classification, 1992.
Determinant based atlanta classification(2012)
Revised Atlanta classification, 2013
•ORGAN FAILURE
•LOCAL COMPLICATIONS
*RANSON’S SCORE>/=3
*APACHE II SCORE >/=8

6.  Local determinants:
Fluid collections
Necrosis of pancreas +/
 Peripancreatic tissue
(covered by the term
peripancreatic necrosis)
 Systemic determinants:
 Certain degree of OF due to
AP
Define Organ failure:
Shock
Pulmonary insufficiency
Renal failure after rehydration
GI bleeding

7. According to the Revised Atlanta Classification -
complications of AP can be
 Organ failure
 Organ failure to be evaluated by the Modified Marshall Scoring
System.
 Organ failure = Marshall Score ≥ 2
 Local complications
 Systemic complications
Organ failure:
 Transient: resolves within
48 h of onset
 Persistent : persists ≥ 48 h
REVISED ATLANTA CLASSIFICATION

8.  Local complications:
o Fluid collections
o Gastric outlet dysfunction,
o Splenic and portal vein thrombosis, and
o Colonic necrosis.
Four discrete types of collections:
• Acute peripancreatic fluid collection (APFC),
• Pancreatic pseudocyst (PP)
• Acute necrotic collection (ANC)
• Walled off necrosis (WON)

9. Atlanta
classification(1992)
Revised Atlanta
classification (2013)
Determinant based
classification(2012)
Mild AP:
 Minimal organ dysfunction
and uneventful recovery
 Absence of organ failure
and/or local complications
Severe AP:
 Organ failure and/or local
complications
Mild AP:
 No organ failure
 No local or systemic
complications
Moderately severe AP:
 Transient organ failure
AND/OR local or systemic
complication OR
exacerbation of pre-
existing co-morbidities
Severe AP:
 Persistent organ failure
(single/multiple)
Mild AP:
 No organ failure
 No (peri) pancreatic necrosis
Moderate AP:
 Sterile (peri) pancreatic
necrosis AND/OR transient
organ failure
Severe AP:
 Infected (peri) pancreatic
necrosis OR persistent organ
failure
Critical AP:
 Infected (peri) pancreatic
necrosis AND persistent
organ failure

10. WHY A SEVERITY STRATIFICATION IS NEEDED:-

11. WHY A SEVERITY STRATIFICATION IS NEEDED:-
Diagnosis
Severity
stratificationPredicted mild
disease
Predicted
severe
disease
Aetiological
assessment
Management
on ward
Treatment of
other
aetiological
factors
Referral to a
specialist unit
Eradication of
gallstones
Management on
HDU/ITU
Dynamic CT
?ERCP
Monitor for
complications
Management of
complications

12. Pathology-specific scoring systems
 Ranson
 Glasgow and Imrie
To evaluate patients in intensive care units
 APACHE scoring systems (APACHE II)
To distinguish and diagnosis local complications.
 CT severity index(CTSI)
Organ Failure (OF) Based Scoring Systems / should be treated in ICU
 Marshall
SOFA
To predict the mortality risk during the first 24 hours of the diseases.
 BISAP

13. Ranson criteria
Upon admission:
1) Age > 55 years
2) WBC > 16000/mm3
3) Glucose > 200 mg /dl
4) LDH > 350 IU/L
5) AST > 250 IU/L
Within 48 hours
1) Drop in HCT > 10%
2) Serum Calcium < 8 mg/dl
3) Base deficit > 4mE/L
4) Increase BUN > 5 mg/dl
5) Fluid deficit > 6L
6) Arterial PO2 < 60 mm Hg
Modified Glasgow System
1) Arterial PO2 <60 mm Hg
2) Ser albumin<3.2 mg/dl
3) Ser Calcium<8 mg/dl
4) WBC > 15000/mm3
5) AST > 200 IU / L
6) LDH > 600 IU/L
7) Glucose > 180 mg /dl
8) BUN > 45 mg/dl

14. Upon admission:
1) Age > 70 years
2) WBC > 18000/mm3
3) Glucose > 220 mg /dl
4) LDH > 400 IU/L
5) AST > 440 IU/L
Within 48 hours
1) Drop in HCT > 10%
2) Serum Calcium < 8 mg/dl
3) Base deficit > 4mE/L
4) Increase BUN > 2 mg/dl
5) Fluid deficit > 6L
6) Arterial PO2 < 60 mm Hg

16.  First major attempts to quantify the severity of the illness in ICU
patients
 It contains 12 continuous variables
The major advantage of the APACHE II scoring system:
It can be used in monitoring the patient’s response to therapy
(Ranson and the Glasgow scales are mainly meant for the assessment
at presentation)

17.  (1) Body temperature,
 (2) mean arterial pressure
(mm Hg),
 (3) Heart rate(HR),
 (4) respiratory rate (R.R/mt),
 (5) Oxygenation (mm Hg),
 (6) PH,
 (7) Na (mmol/l),
 (8) k (mmol/l),
 (9) Creatinine (mg/100ml),
 (10) Haematocrit,
 (11) total leucocyte count and
the
 (12) Glasgow coma score.
APACHE II - Score ≥ 8: organ failure / Substantial pancreatic necrosis
Score ≥ 3: severe pancreatitis likely.
Score Mortality
0-2 2%
3-4 15%
5-6 40%
7-8 100%
APACHE II score > 8 points
predicts 11% to 18%
mortality.

18.  APACHE О is proposed by
Johnson et al
 In patients with a BMI >
30,
 It showed similar results
between APACHE O and
APACHE II

19.  Grading system used to determine the severity of acute
pancreatitis.
 The numerical CTSI has a maximum of ten points
 It is the sum of the Balthazar grade points and pancreatic
necrosis grade points

20. CT SEVERITY INDEX
(BALTHAZAR, 1990)
MODIFIED CT SEVERITY
INDEX
(MORTELE, 2004)
PROGNOSTIC
INDICATOR
POINTS PROGNOSTIC
INDICATOR
POINTS
PANCREATIC
INFLAMMATION
PANCREATIC
INFLAMMATION
NORMAL
PANCREAS
0 NORMAL
PANCREAS
0
ENLARGED
PANCREAS
1 PANCREATIC ABN
+/-
PERIPANCREATIC
INFLAMMATION
2
PANCREATIC
ABNORMALITIES
WITH
PERIPANCREATIC
INFLAMMATION
2 PANCREATIC OR
PERIPANCREATIC
FLUID
COLLECTION/ FAT
NECROSIS
4
SINGLE FLUID
COLLECTION
3
2/MORE
COLLECTION OR
GAS
4
CT SEVERITY INDEX
(BALTHAZAR,1990)
MODIFIED CT SEVERITY
INDEX
(MORTELE,2004)
PROGNOSTIC
INDICATOR POINTS
PROGNOSTIC
INDICATOR POINTS
PANCREATIC
NECROSIS
PANCREATIC
NECROSIS
NONE 0 NONE 0
<30% 2 <30% 2
30-50% 4 >30% 4
>50% 6 EXTRAPANCREATIC
COMPLICATIONS
2

21. Type of
Pancreatitis
Ranson’s
criteria
APACHE II CT Severity
Index
Mild Pancreatitis ≤ 3 < 8 < 7
Severe
Pancreatitis
> 3 ≥ 8 ≥ 7

22. Most sensitive for evaluation of AP patients.
 50% of the patients with necrotising acute pancreatitis develop
organ failure with severe acute pancreatitis.
 15% of edematous acute pancreatitis develop organ failure.
Score > 3 is associated with
 Severe course,
 Systemic complications and
 Significant correlation with fatal outcome (Р = 0.007) .

23. Organ system Score
0 1 2 3 4
Respiratory
(PaO2/FiO2)
>400 301-400 201-300 101-200 <100
Renal
(Serum
Creatinine
md/dl)
≤1.5 >1.5 - ≤
1.9
>1.9 - ≤ 3.5 >3.5 - ≤
5.0
> 5.0
Cardiovascular
(systolic blood
pressure, mm
Hg)
>90 <90, fluid
responsive
<90, fluid
unresponsive
<90,
pH<7.3
<90,
pH<7.2

24.  It is a mortality prediction score that is based on the degree of
dysfunction of 6 organ systems.
 The score is calculated on admission and every 24 hours until
discharge using the worst parameters measured during the prior
24 hours.

25. SOFA Score
Variables 0 1 2 3 4
Respiratory
(PaO2/FiO2)
> 400 ≤ 400 ≤ 300 ≤ 200 ( with respiratory support) ≤ 100
(with respiratory support)
Coagulation
( Platelets x
103/µL)
> 150 ≤ 150 ≤ 100 ≤ 50 ≤ 20
Liver
( Bilirubin: mg/dl)
< 1.2 1.2 – 1.9 2.0 – 5.9 6.0 – 11.9 > 12.0
Cardiovascular
(Hypotension)
No
hypotension
Mean Arterial
Pressure < 70
mm of Hg
Dopamine ≤ 5
(microgram/kg/min) or
Dobutamine (any dose)
Adrenergic agents administered
for atleast one hour
Dopamine > 5 (microgram/kg/min),
Epinephrine ≤ 0.1
(microgram/kg/min), or
Norepinephrine ≤ 0.0
Adrenergic agents administered for
atleast one hour
Dopamine > 15
(microgram/kg/min),
Epinephrine > 0.1
(microgram/kg/min), or
Norepinephrine > 0.0
Adrenergic agents
administered for atleast one
hour
Central nervous
system
(Glasgow coma
scale)
15 13-14 10-12 6-9 <6
Renal
(Creatinine –
mg/dl or Urine
output ml/day
<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or < 500 > 5.0 or < 200

26. 1. BUN > 25mg/dl.
2. Impaired mental status ( Glasgow Coma Score < 13)
3.
SIRS
4. Age > 60 years
5. Pleural effusion detected on imaging.
One point is assigned for each variable within 24 hours of
presentation and added for a composite score of 0-5.
• Incremental increases in the
BISAP score (3 or more)
have been shown to
correlate with an increased
risk of organ failure
pancreatic necrosis and
mortality

27. WHAT WE ARE USING IN MLDMCH
•RANSON’S *BALTHAZAR *APACHEII
WHAT WE AIM AT USING
•APACHEII *MARSHALL’S *SOFA

28.  Severity stratification should be made
in all patients within 48 hrs.
 It is recommended that all patients should
be assessed by glasgow score and CRP.
 The APACHE II score is equally accurate and
may be used for initial assessment and
ongoing monitoring in severe cases.