Page 19 - Acute Pancreatitis (Viêm tụy cấp)

910 PART VII Pancreas

presepsin, 256 soluble urokinase-type plasminogen activator recep- TABLE 58.1 CT Grading System of Balthazar and the CT Severity Index
tor, 257 urinary neutrophil gelatinase-associated lipocalin, 258 the (CTSI)
LP-PLA2 gene polymorphisms V279F and R92H, 259 genetic
polymorphisms in TLR3 and TLR6, 260 increased visceral adipose Balthazar
tissue, 261 matrix metalloprotease-8, 262 IL13/IFN gamma ratio, 263 Grades Definition Points
antithrombin-III, 264 high visceral fat with low skeletal muscle vol- A Normal pancreas consistent with mild 0
ume, 265 admission heart rate variability, 266 and others. pancreatitis
The presence of SIRS at admission and persistence of SIRS B Focal or diffuse enlargement of the gland, 1
at 48 hours increases the morbidity and mortality rate. In one including contour irregularities and
study, death occurred in 25% of patients with persistent SIRS, inhomogeneous attenuation but without
in 8% with transient SIRS, and in less than 1% without SIRS. 267 peripancreatic inflammation
Although severity is now defined by the presence of organ fail- C Grade B plus peripancreatic inflammation 2
ure or anatomic complications of AP, such as pancreatic necrosis, D Grade C plus associated single fluid collection 3
prospective systems using clinical criteria have been developed to
determine disease severity. These systems include the Ranson’s E Grade C plus 2 or more peripancreatic fluid 4
and APACHE scores. 13,14 Unfortunately, these scoring systems collections or gas in the pancreas or
retroperitoneum
(discussed below) are cumbersome, requiring multiple measure- CTSI=Balthazar Grade Points Plus Necrosis Score*
ments. In addition, the systems are not accurate until 48 hours
after presentation. Necrosis Score Points
Absence of necrosis 0
Scoring Systems Necrosis of up to 33% of the pancreas 2

APACHE II has been the most validated system for many years Necrosis of 33%-50% 4
and none of the later scoring systems later reported proved to Necrosis of >50% 6
be superior in any consistent manner. However, APACHE II is
*Highest attainable CTSI score: 4 (Balthazar grade E) + 6 (necrosis of
cumbersome (like most of the systems) and is very rarely used in >50%) = 10 points.
clinical practice. Most studies used a score of 8 or more as severe
AP. Ranson and colleagues identified 11 signs that had prognostic
13
significance during the first 48 hours. The original list was ana-
lyzed in patients who primarily suffered from alcoholic pancre- with scores of 7 to 10. The CT grading scores correlate better
atitis and was then modified 8 years later for those with gallstone with local complications (pseudocysts and abscesses) than with
pancreatitis. 268 A score of 3 or more is considered to indicate mortality. Among the 37 patients with a grade D or E score, 54%
severe AP. The Imrie or Glasgow score 269 is a slightly simplified developed a local complication, whereas only 2 of 51 (3.9%) with
list (8 criteria) that is used commonly in the United Kingdom. grades A through C developed this problem. 213 Thus the data
The Pancreas Center at Brigham and Women’s Hospital per- do not confirm that the CTSI is any more predictive than the
formed a series of studies retrospectively and prospectively. 270-272 grades A through E score. There is controversy in the literature
The studies were performed on a large database including almost as to whether the extent of necrosis on CT predicts organ fail-
37,000 patients from more than 200 hospitals. After careful anal- ure. 11,12,16,245-247 A modified CTSI has been found to be more
ysis, including a validation study, they determined that a simpler useful where a simplified assessment of inflammation and necro-
system that included only 5 variables could accurately predict sis, as well as assessment of extrapancreatic complications, were
severity early in the course of the disease. The scoring system, included. 276
referred to as BISAP (Bedside Index for Severity in AP), assigns
each parameter 1 point: BUN greater than 25 mg/dL, Impaired Chest Radiography
mental status, SIRS, Age older than 60 years, and Pleural effu-
sion, for a possible total of 5 points. A BISAP score of 4 or 5 is A pleural effusion documented within 72 hours of admission by
associated with a 7- to 12-fold increased risk of developing organ chest radiography (or CT) correlates with severe disease. 205,206
failure. BISAP is not superior to APACHE II. Other scoring sys-
tems include the harmless AP score, 273 the Japanese AP severity TREATMENT (FIG . 58 .5)
score, 274 and the PANC 3 score. 275
APACHE II has stood the test of time and no score is convinc- Initial Management During the First Week
ingly superior to it, but it has the drawback of being cumbersome.
The simple SIRS score is as good as any of the complex scoring There is no specific drug therapy to treat AP and, thus, treatment
systems that are available and is easy, cheap, and readily available guidelines are mainly for supportive care and for the treatment of
at the time of admission. 125 SIRS is defined by 2 or more of the complications once they develop. However, because of such good
following 4 criteria: pulse >90 beats/minute, rectal temperature supportive care, including ICU care and more effective therapy
3
<36°C or >38°C, WBC count <4000/mm or >12,000/mm , and of the ensuing complications, the mortality in AP has dropped
3
a respiratory rate greater than 20/minute or an arterial PCO 2 <32 from around 10% to 5% or less from different regions of the
mm Hg (see Box 58.2). world. The patient is usually kept NPO until any nausea and
vomiting have subsided. However, there has been a major change
CT in this concept and currently gut rousing and not gut resting is
By providing earlier oral intake, the gut
the key management.
277
The finding of extensive fluid collections and/or extensive pan- mucosal barrier is preserved and prevents the undesirable trans-
creatic necrosis on CT has been correlated with severe disease. location of bacteria from the lumen into circulation. Pain relief
Balthazar reported that 5 of 37 (13.5%) patients who had grade is an important area in the early management. Opiate analgesics
D or E findings on CT died, as opposed to none of 51 who had like fentanyl and hydromorphone often by a patient-controlled
grades B or C findings (Table 58.1). 213 Using the CT severity anesthesia pump are the most widely used agents. 278 Opiate dos-
index (CTSI score; see Table 58.1), among those with a score ing is monitored carefully and adjusted on a daily basis accord-
of 0 to 6, 3 of 77 (3.8%) died, as compared with 2 of 11 (18%) ing to ongoing needs. Although morphine has been reported to