Title: Predicting Factors of Pancreatic Infection in Acute Necrotizing Pancreatitis: A Report of 119 Cases
Authors: Mohamed Ben Mabrouk, Bassem Nasr, Waad Farhat, Mohamed Ben Rejeb, Malek Barka, Said Nakhli, Mohamed Azzaza, Fethia Harrabi, Walid Naija, Ali Ben Ali
DOI: http://dx.doi.org/10.18535/jmscr/v3i10.53
Abstract
Introduction: acute Necrotizing pancreatitis (ANP) represents the severe form of human acute pancreatitis (15% of cases). Infection of pancreatic necrosis occurs in 40– 70 % of patients with ANP and have mortality rate about 80% of cases. Therefore, early prediction and diagnosis of infection in ANP are extremely important. So we aimed to identify the risk factors for predicting pancreatic infection in patients with ANP.
Methods: One hundred and nineteen patients with ANP were included and divided into two groups based on the presence or absence of pancreatic infection. Demographic and clinical characteristics, laboratory examination results, complications and treatment modalities of these patients were collected from their medical records. Variables were initially screened by univariate analysis and those with statistical significance were then filtered by multivariate analysis to determine the independent risk factors for pancreatic infection in ANP.
Results: Patients having ANP with pancreatic infection were more obese and had dyslipidemia more than patients without pancreatic infection. In addition; they had lower partial pressure of arterial CO2, as well as a higher computed tomography severity index (CTSI) and Ranson’s score than those without pancreatic infection, while their lactate dehydrogenases and CRP levels, hematocrit and glycaemia were much higher. Pancreatic infection also occurred more commonly in patients receiving delayed enteral nutrition than in those who received early enteral nutrition. Multivariate analyses revealed that only high CTSI was independent risk factor for pancreatic infection in ANP.
Conclusion: many variables were initially identify by univariate analysis as predicting factors of necrosis infection but only high CTSI was independent risk factor.
Keywords:Acute pancreatitis- infection – predictive factor- prognostic
References
1. T. L. Bollen, H. C. van Santvoort, M. G. Besselink, M. S. van Leeuwen, K. D. Horvath, P. C. Freeny et al. The Atlanta Classification of acute pancreatitis revisited. British Journal of Surgery 2008; 95:6–21.
2. BüchlerMW1, Gloor B, Müller CA, Friess H, Seiler CA, Uhl W. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000; 232: 619–26.
3. Lankisch PG, Schirren CA. Increased body weight as a prognostic parameter for complications in the course of acute pancreatitis. Pancreas 1990; 5: 626-9.
4. Porter KA, Banks PA. Obesity as a predictor of severity in acute pancreatitis.Int J Pancreatol 1991; 10: 247-52.
5. C. Funnell, P. C. Bornman, S. P. Weakley, J. Terblanche and I. N. Marks. Obesity: an important prognosticfactor in acute pancreatitis. Br. J. Surg. 1993, Vol. 80, April, 484-486.
6. Beger HG, Bittner R, Block S, Biicher M. Bacterial contamination of pancreatic necrosis: a prospective clinical study. Gastroenterology 1986; 91: 433-8.
7. UHL W, Büchler M, Malfertheiner P, Martini M, Beger HG. PMN-elastase in comparison with CRP, antiproteases, and LDH as indicators of necrosis in human acute pancreatitis.Pancreas 1991; 6: 253–9.
8. ZrnicIK1, Milic S, Fisic E, Radic M, Stimac D. C-reactive protein and lactate dehydrogenase as single prognostic factors of severity in acute pancreatitis. LijecVjesn 2007; 129: 1–4 (in Croatian).
9. RansonJH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis.Surg Gynecol Obstet 1974; 139: 69–81.
10. Ogawa M, Hirota M, Hayakawa T et al. Development and use of a new staging system for severe acute pancreatitis based on a nationwide survey in Japan. Pancreas 2002; 25: 325–30.
11. Rau B, Cebulla M, Uhl W, Schoenberg MH, Beger HG. The clinical value of human pancreas-specific protein procarboxypeptidase B as an indicator of necrosis in acute pancreatitis: comparison to CRP and LDH. Pancreas 1998; 17: 134–9.
12. Yan Bo Zeng, Xian Bao ZHAN, Xiao Rong GUO, HuaGao ZHANG, Yan CHEN, QuanCaiCAI, Zhao Shen LI. Risk factors for pancreatic infection in severe acute pancreatitis. Journal of digestive diseases july 2014;15(7):377-385.
13. Dambrauskas Z, Pundzius J, Barauskas G. Predicting development of infected necrosis in acute necrotizing pancreatitis. Medicina (Kaunas) 2006; 42: 441–9.
14. Riche FC, Cholley BP, LaisneMJ, Vicaut E, PanisYH, LajeunieEJ, Boudiaf M, Valleur PD. Inflammatory cytokines, C-Reactive protein, and procalcitonin as early predictors of necrosis infection in acute necrotizing pancreatitis. Surgery 2003;133(3):257-62.
15. Rau B, Steinbach G, Gansauge F, Mayer JM, Grunert A, Beger HG. The potential role of procalcitonin and interleukin 8 in the prediction of infected necrosis in acute pancreatitis. Gut 1997;41(6):832-40.
16. Armengol-Carrasco M, Oller B, Escudero LE, Roca J, Gener J, Rodriguez N, del Moral P, Moreno P. Specific prognostic factors for secondary pancreatic infection in severe acute pancreatitis. Dig Surg 1999;16(2):125-9.
17. ller CA, Uhl W, Printzen G et al. Role of procalcitonin and granulocyte colony stimulating factor in the early prediction of infected necrosis in severe acute pancreatitis. Gut 2000; 46: 233–238.
18. Gray SH&Rosenman LD. Acute pancreatitis. The significance of hemoconcentration at admission to the hospital. Arch Surg 1965: 485–489.
19. Brown A, Orav J & Banks PA. Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas 2000; 20: 367–372.
20. Gan SI &Romagnuolo J. Admission hematocrit: a simple, useful and early predictor of severe pancreatitis. Dig Dis Sci 2004; 49: 1946–1952.
21. Remes-Troche JM, Duarte-Rojo A, Morales G et al. Hemoconcentration is a poor predictor of severity in acute pancreatitis. World J Gastroenterol 2005; 11: 7018–7023.
22. Baillargeon JD, Orav J, Ramagopal V et al. Hemoconcentration as an early risk factor for necrotizing pancreatitis. Am J Gastroenterol 1998; 93: 2130–2134.
23. Noel RA, Braun DK, Patterson RE, Bloomgren GL. Increased risk of acute pancreatitis and biliary disease observed in patients with type 2 diabetes: a retrospective cohort study. Diabetes Care 2009; 32: 834-838.
24. Girman CJ, Kou TD, Cai B, Alexander CM, O’Neill EA, WilliamsHerman DE, Katz L. Patients with type 2 diabetes mellitus have higher risk for acute pancreatitis compared with those without diabetes. Diabetes ObesMetab 2010; 12: 766-771.
25. Lai SW, Muo CH, LiaoKF, Sung FC, Chen PC. Risk of acute pancreatitis in type 2 diabetes and risk reduction on antidiabetic drugs: a population-based cohort study in Taiwan. Am J Gastroenterol 2011; 106: 1697-1704.
26. RansonJH. Etiological and prognostic factors in human acute pancreatitis: a review. Am J Gastroenterol 1982; 77: 633-638.
27. Mentula P, Kylänpää ML, Kemppainen E, Jansson SE, Sarna S, Puolakkainen P, Haapiainen R, Repo H. Early prediction of organ failure by combined markers in patients with acute pancreatitis. Br J Surg 2005; 92: 68-75.
28. Xiu F, Stanojcic M, Diao L, Jeschke MG. Stress hyperglycemia, insulin treatment, and innate immune cells. Int J Endocrinol 2014; 2014: 486403.
29. Kazuhiro Kikuta, Atsushi Masamune, TooruShimosegawa. Impaired glucose tolerance in acute pancreatitis. World J Gastroenterol 2015 June 28; 21(24): 7367-7374.
30. Buter A, ImrieCW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 2002; 89: 298–302.
31. Werner J, Uhl W, Hartwig W et al. Modern phase-specific management of acute pancreatitis. Dig Dis 2003; 21: 38–45.
32. ImrieCW, Ferguson JC, Murphy D, BlumgartLH. Arterial hypoxia in acute pancreatitis.Br J Surg 1977; 64: 185–8.
33. De Troyer A, Naeije R, YernaultJC, Englert M. Impairment of pulmonary function in acute pancreatitis. Chest 1978; 73: 360–3.
34. Salomone T, Tosi P, Di Battista N et al. Impaired alveolar gas exchange in acute pancreatitis. Dig Dis Sci 2002; 47: 2025–8.
35. Polyzogopoulou E, Bikas C, Danikas D, Koutras A, Kalfarentzos F, Gogos CA. Baseline hypoxemia as a prognostic marker for pulmonary complications and outcome in patients with acute pancreatitis. Dig Dis Sci 2004; 49: 150–4
36. Halonen KI, Leppaniemi AK, Lundin JE, Puolakkainen PA, KemppainenEA, HaapiainenRK. Predicting fatal outcome in the early phase of severe acute pancreatitis by using novel prognostic models.Pancreatology 2003;3(4):309-15.
37. Balthazar Emil J, Freeny Patrick C, VanSonnenberg Eric. Imaging and intervention in Acute Pancreatitis. Radiology 1994;193:297-306.
38. Vege SS, Fletcher JG, Talukdar R, Sarr MG (2010) Peripancreatic collections in acute pancreatitis: correlation between computerized tomography and operative findings. World J Gastroenterol 16:4291–6.
39. Balthazar Emil J, Robinson David L, Megibow Alec j, Ranson John H.C. Acute Pancreatitis:Value of CT in Establishing Prognosis. Radiology 1990;174:331-336.
40. Balthazar Emil J. Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002;223: 603-613.
41. Mortele Koenraad J, Wiesner W, IntriereL,Shankar S, ZouKelly.H, KalantariBabek N, Perez A, van Sonnenberg E, Ros Pablo R, Banks Peter A, silverman Stuart G. A modified CT severety Index for Evaluating Acute Pancreatitis:Improved Correlation with Patient outcome.AJR 2004;183:1261-1265.
42. MacDonald TT. The mucosal immune system. Parasite Immunol 2003;25: 235-246.
43. Cunningham-Rundles S. Nutrition and the mucosal immune system. CurrOpin Gastroenterol 2001;17: 171-176.
44. Hegazi R, Raina A, Graham T, Rolniak S, Centa P, Kandil H, O’Keefe SJ. Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr 2011;35: 91-96.
45. Oláh A, Romics L. Early enteral nutrition in acute pancreatitis—benefits And limitations. Langenbecks Arch Surg 2008;393:261-269.
46. Jia-Kui Sun, Xin-Wei Mu, Wei-Qin Li, Zhi-Hui Tong, Jing Li, Shu-Yun Zheng. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. World J Gastroenterol 2013 February 14; 19(6): 917-922.
47. Urszula Wereszczynska-Siemiatkowska, Agnieszka Swidnicka-Siergiejko, Andrzej Siemiatkowski and AndrzejDabrowski, Early Enteral Nutrition Is Superior to Delayed Enteral Nutrition for the Prevention of Infected Necrosis and Mortality in Acute Pancreatitis. Pancreas J,Volume 42, Number 4, May 2013 : 640-646.