Page 43 - GTM-3-2

Global Translational Medicine Prognostic indicators and management of SAP

Table 1. Atlanta classification for acute pancreatitis or in the periumbilical area (Cullen sign), holds significant
prognostic value. However, they are very inconsistent and
Stages Description are found in < 3% of cases of SAP. A rise in intra-abdominal
16
Mild Acute pancreatitis without obvious pancreatic necrosis. pressure (IAP) is correlated with the severity of the attack;
Severe (i) Visceral failure an IAP of more than 14 mmHg is considered a reliable and
• Systolic arterial pressure (SAP) < 90 mmHg; early marker of a severe form of AP. The MVFS is the most
17
• Partial pressure of oxygen (PaO ) ≤ 60 mmHg; relevant factor in the unfavorable clinical outcome of SAP. 16
2
• Creatinine>176.8 µmol/L;
• Digestive hemorrhage>500 mL/24 h.
(ii) Local complications: Necrosis, pseudocysts, and abscesses. 2.1.2. Biochemical factors
(iii) Ranson score>3. A CRP level exceeding 150 mg/L within the first 48 h is
(iv) APACHE II score>8. indicative of pancreatic necrosis, with sensitivity and
(v) C-reactive protein (CRP) at 48 h>150 mg/dL. 18,19
Necrosis Presence of a localized or diffuse pancreatic or peripancreatic specificity both exceeding 80% and an accuracy of 86%.
However, this assay is of no value in detecting infection
non-viable zone.
with pancreatic necrosis. Similarly, a serum amyloid A
20
level of over 280 mg/L indicates pancreatic necrosis, with a
for 90% of SAP. Other causes include hypertriglyceridemia, sensitivity of 69% and a specificity of 67%. 21
anatomical abnormalities, drugs, and trauma. However, On the other hand, procalcitonin is not considered
7
etiology has no influence on the severity of the condition.
a good indicator of pancreatic necrosis, but it serves as
The primary treatment for SAP involves resuscitation an excellent indicator of infection, whether bacterial or
and intensive care, with surgery reserved as a secondary fungal. Regarding the interleukin family, only interleukin
22
treatment in the event of complications. It is also useful 6 is of value in diagnosing severity. Its levels increase in
in the treatment of biliary etiology. The prognosis remains SAP from day 1, peaking at 72 h. 23
guarded in severe cases. The overall mortality rate for all Moreover, granulocyte polymorphonuclear elastase is
forms of AP is 5%, with a breakdown of 3% for moderate an early prognostic factor for severity, with a sensitivity of
cases, 17% for severe cases, and 35% for instances involving 92%, a specificity of 91%, and an accuracy of 91%. When
infected necrosis, especially when associated with MVFS. exceeding a threshold value of 110 µg/L, its positive and
8,9
In the case of infection, mortality varies between 40% and negative predictive values are 78% and 96%, respectively,
70%, depending on the study. The implementation of in detecting the severity of the disease. 24,25 Unfortunately,
10
precise algorithms for SAP management, coupled with the not all of these markers can be detected in time, and their
constant monitoring of compliance, has enabled Japan to measurement cannot be generalized to all centers. Recently,
reduce the mortality rate for severe forms to 10.1%. The the measurement of the soluble fraction of E-cadherin in
11
major challenge in managing this condition is identifying blood has emerged as an early marker of severity that can
an “ideal marker” early on to predict which patients be used during the first 12 h, thus facilitating improved
are likely to develop severe forms so that they can be patient referral. 26
transferred immediately to a referral center where they will
be treated by a trained multidisciplinary team of surgeons, 2.1.3. Clinical-biological scores
gastroenterologists, and interventional radiologists. To
date, such an “ideal marker” has not been identified; The Ranson score (Table 2) assigns a point (01) to each
therefore, this review aims to analyze available predictive parameter, resulting in a Ranson index ranging from 1
tools and subsequent therapeutic strategies. – 11. AP is considered severe when the Ranson index is
greater than or equal to three, and mortality approaches
2. Diagnosis of severity 100% when the number of points is greater than or equal
to seven. However, the Ranson score cannot be assessed
2.1. Future prospects before the 48 h, lacks reproducibility, and is not employed
th
2.1.1. Clinical elements for screening complications.
Generally, clinical presentation is a poor indicator of The Imrie or Glasgow score (Table 3) serves as a practical
attack severity. Upon admission, a comprehensive clinical simplification of the Ranson score, assessing all criteria
examination detects less than 44% of severe forms. upon the patient’s admission. The APACHE II score (Acute
12
Obesity (with a body mass index >30), age over 70, and Physiology and Chronic Health Examination) includes
chronic alcoholism appear to be the factors that aggravate criteria such as age, associated defects, hemodynamic,
the condition. 8,13-15 The presence of signs of loco-regional respiratory, and neurological criteria (Glasgow scale). In
diffusion, such as necrotic spots on the flanks (Grey Turner) addition, it involves the assessment of renal, hematological,

Volume 3 Issue 2 (2024) 2 doi: 10.36922/gtm.2480