Fig. 10.1
(a) Peripancreatic inflammation and fluid. (b) Irregular heterogenous enhancement of the pancreatic gland with peripancreatic inflammation and fluid suggestive of pancreatic necrosis, along with mesentery infiltration. (c) Severe pancreatic necrosis with surrounding fluid and phlegmon
Although more expensive and less available, magnetic resonance imaging (MRI) with gadolinium contrast is a reliable method in the evaluation of acute pancreatitis. MRI has fewer contraindications than CT, and is an ideal substitute in pregnant patients or those with renal insufficiency. It is especially useful in visualizing complications of gallstone pancreatitis such as hemorrhage and has the ability to differentiate fluid collections from liquefied necrosis [30]. Magnetic resonance cholangiopancreatography (MRCP) involves a specific MRI protocol designed to enhance the fluid signal within the biliary system allowing for more accurate delineation of biliary and pancreatic anatomy. Filling defects and anatomic disruptions in the pancreatic duct can be better appreciated, and many clinicians use MRCP as a screening tool to select patients for ERCP. The sensitivity of MRCP for detecting choledocholithiasis has been reported to be 85–90 %, making it an ideal study when CBD stones are suspected [31].
Severity of Disease
In gallstone pancreatitis there is a wide spectrum of disease. Although as many as 80 % of patients will have a benign course, the remaining 20 % can have severe disease with a mortality rate in this group as high as 30 % [32, 33]. Mortality associated with this disease is often due to multisystem organ failure (MOF) and later to septic complications of pancreatic necrosis. Many have sought to develop prognostic scoring systems or markers in order to identify patients most at risk. Multiple studies have evaluated the ability of clinicians alone to differentiate between mild and severe AP. Sensitivity of clinical assessment alone ranges from 34 to 64 %, suggesting that without additional disease severity stratification tools, many patients with severe pancreatitis might not be triaged to the appropriate level of care [34, 35].
Ranson Criteria
Ranson Criteria (Table 10.1) is the most frequently used multifactorial scoring system in the United States. It was first introduced by Ranson et al. in 1974 to score the severity of alcoholic-induced pancreatitis and later modified for gallstone pancreatitis in 1979 [36]. It is based on 11 clinical and laboratory data points in nonbiliary pancreatitis, and ten data points in gallstone pancreatitis (arterial oxygen saturation (PaO2) is omitted from the original scoring system). Data points are collected at presentation and at 48 h into the hospital course. A score of three or more is the cutoff for severe pancreatitis, however, mortality predictions are not accurate until 48 h into the course of acute pancreatitis.
Table 10.1
Ranson criteria
Gallstone pancreatitis | Nongallstone pancreatitis | |
|---|---|---|
At admission | ||
Age (years) | >70 | >55 |
WBC (cells/μL) | >18 K | >16 K |
Blood glucose (mg/dL) | >220 | >200 |
Serum AST (U/L) | >250 | >250 |
Serum LDH (U/L) | >400 | >350 |
At 48 h | ||
Serum calcium (mmol/L) | <8 | <8 |
Hematocrit fall (%) | >10 | >10 |
PaO2 (mmHg) | Omitted | <60 |
BUN increase (mg/dL) | >2 | >5 |
Base deficit (mEq/L) | >6 | >4 |
Sequestration of fluid (L) | >4 | >6 |
APACHE-II
The Acute Physiology and Chronic Health Evaluation II (APACHE-II) scoring system was developed by Knaus et al. in 1985 [37]. It was initially developed to estimate mortality in all patients admitted to an intensive care unit (ICU) but has been widely applied to patients with acute pancreatitis. It offers a distinct advantage over Ranson Criteria because it can be calculated at any time during the hospital admission, and changes in the APACHE-II score have been shown to correlate with clinical improvement or deterioration. The score is a composite of 12 individual variable points, age points, and chronic health points (Table 10.2). Calculating an APACHE-II score can be cumbersome (Table 10.3), and this difficulty in clinical practice is often cited as its greatest shortcoming. An APACHE-II score of eight or above is indicative of severe disease [38].
Table 10.2
APACHE-II parameters and units of measurement
Age (years) |
Temperature (°C) |
Mean arterial pressure (mmHg) |
pH |
Heart rate (beats per min) |
Respiratory rate (breaths per min) |
Serum sodium (mEq/L) |
Serum potassium (mEq/L) |
Serum creatinine (mg/dL) |
Hematocrit (%) |
WBC (cells/μL) |
Glasgow-coma-scale (points) |
A—a gradient (if FiO2 ≥0.5) (mmHg) |
PaO2 (if FiO2 <0.5) (mmHg) |
History of organ insufficiency |
History of immunocompromise |
Table 10.3
The APACHE-II severity of disease classification system
Physiologic variable | +4 | +3 | +2 | +1 | 0 | +1 | +2 | +3 | +4 | |
Temperature—rectal (°C) | ≥41 | 39–40.9 | 38.5–38.9 | 36–38.4 | 34–35.9 | 32–33.9 | 30–31.9 | ≤29.9 | ||
Mean arterial pressure (mmHg) | ≥160 | 130–159 | 110–129 | 70–109 | 50–69 | ≤49 | ||||
Heart rate | ≥180 | 140–179 | 110–139 | 70–109 | 55–69 | 40–54 | ≤39 | |||
Respiratory rate (nonventilated or ventilated) | ≥50 | 35–49 | 25–34 | 12–24 | 10–11 | 6–9 | ≤5 | |||
Oxygenation (mmHg) a. FiO2 > 0,5 use A-aDO2 | a | ≥500 | 350–499 | 200–349 | <200 | |||||
b. FiO2 <0,5 use PaO2 | b | >70 | 61–70 | 55–60 | <55 | |||||
Arterial pH | ≥7.7 | 7.6–7.69 | 7.5–7.59 | 7.33–7.49 | 7.25–7.32 | 7.15–7.24 | <7.15 | |||
Serum sodium (mmol/L) | ≥180 | 160–179 | 155–159 | 150–154 | 130–149 | 120–129 | 111–119 | <110 | ||
Serum potassium (mmol/L) | ≥7 | 6–6.9 | 5.5–5.9 | 3.5–5.4 | 3–3.4 | 2.5–2.9 | <2.5 | |||
Serum creatinine (mg/dL, Double point score for acute renal failure) | ≥3.5 | 2–3.4 | 1.5–1.9 | 0.6–1.4 | <0.6 | |||||
Hematocrit (%) | ≥60 | 50–59.9 | 46–49.9 | 30–45.9 | 20–29.9 | <20 | ||||
White blood count (in 1000/mm5) | ≥40 | 20–39.9 | 15–19.9 | 3–14.9 | 1–2.9 | <1 | ||||
Glasgow-Coma-Scale (GCS) | Score = 15 minus actual GCS | |||||||||
Serum HCO 3 (venous, mmol/L, use if no ABGs) | ≥52 | 41–51.9 | 32–40.9 | 22–31.9 | 18–21.9 | 15–17.9 | <15 | |||
A = Total Acute Physiology Score APS | Sum of the 12 individual variable points | |||||||||
В = Age points | C = Chronic Health Points | |||||||||
≤44 уеars | 0 points | If the patient has a history of severe organ system insufficiency or is immunocompromised, assign points as follows: | ||||||||
45–54 уеars | 2 points | |||||||||
55–64 уеars | 3 points | a. For nonoperative or emergency postoperative patients—5 points | ||||||||
65–74 уеars | 5 points | b. For elective postoperative patients—2 points | ||||||||
≥75 уеars | 6 points | |||||||||
APACHE-II Score = Sum of A (APS points) + В (Age points) + С (Chronic Health points) | ||||||||||
(From: Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE-II: a severity of disease classification system. Crit Care Med 1985; 13(10):818-29)
Glasgow Score
The Glasgow Score, also known as the Glasgow-Imrie Score, is a modification of Ranson’s criteria, that includes age and laboratory data points with alerted cut offs. Hematocrit, base deficit, and fluid sequestration are omitted from this system, while albumin is included. It was published by Imrie et al., in 1984, but its current use is limited to Europe. The Glasgow score has been shown to be equally effective in predicting mortality and is as accurate (though not better than) Ranson’s criteria [35, 39]. Like the Ranson criteria the Glasgow score also requires 48 h to complete; and a score of three or greater is indicative of severe pancreatitis (Table 10.4).
Table 10.4
Glasgow score parameters
P | – PO2 (mmHg) | <60 | |
A | – Age (years) | >55 | |
N | – Neutrophills/WBC (cells/μL) | >15 K | |
C | – Calcium (mmol/L) | <2 | |
R | – Renal function/Urea (mmol/L) | >16 | |
E | – Enzymes | ALT (U/L) | >100 |
LDH (U/L) | >600 | ||
A | – Albumin (g/L) | <32 | |
S | – Sugar/glucose (mg/dL) | >180 | |
CT Severity Index
Balthazar et al. introduced the CT Severity Index (CTSI). Its aim is to grade the severity of acute pancreatitis radiographically and does not take into account clinical parameters [29]. CTSI combines the morphologic features of the pancreas including the degree of pancreatic and peripancreatic inflammation with the degree of necrosis (Fig. 10.1 and Table 10.5). Subsequent modifications of the CTSI have been proposed, but when compared head-to-head with the CTSI of Balthazar, no significant differences were noted in their ability to evaluate the severity of acute pancreatitis. The CTSI score not only correlates with disease severity and mortality, it has also been shown to correlate with the duration of hospitalization, and need for necrosectomy [28]. The CT findings are scored from 0 to 10, and a score of two or greater is indicative of moderate disease. Scores greater than six are associated with higher rates of complications and death [40, 41].
Table 10.5
CT severity index (CTSI)
Grading of pancreatitis | Score | Degree of necrosis | Score | ||
|---|---|---|---|---|---|
A | Normal pancreas | 0 | + | 0 % | 0 |
B | Enlargement of the pancreas | 1 | ≤30 % | 2
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 Damage Control Techniques in Acute Cholecystitis
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