Fulminant Acute Pancreatitis

Česká verzia

Authors: Z. Krška; J. Šváb
Authors place of work: Podpora grantu IGA MZ 8830-4. ; I. chirurgická klinika 1. LF UK a VFN v Praze, přednosta: prof. MUDr. Zdeněk Krška, CSc.
Published in the journal: Rozhl. Chir., 2009, roč. 88, č. 10, s. 563-567.
Category: Monothematic special - Original

Summary

Introduction:
Fulminant acute (FAP) and subfulminant pancreatitis (SFAP) represent the latterly defined subgroup within the severe acute pancreatitis (SAP) with rapidly progressing organ failure (OF) and multi-organ failure MOF high level of lethality and poor effect of both conservative and surgical treatment.

Aim and Methods:
Analysis of indigenous set of patients diagnosed with SAP, particularly with FAP and SFAP, and comparison of data with the literature. Retrospectively prospective study of data collected over the period 2003 to 2007.

Results:
Mild form of AP (MAP) 128 p., etiology %: biliary/alcohol/other – 52/36/12; SAP 106 p., etiology %: biliary/alcohol/other – 51/41/9; ESAP 21 p. i.e. 20 % of SAP, aetiology %: biliary/alcohol/other – 3/27/39. Age: MAP/SAP/ESAP – 43.2/45.8/46.1. Lethality %: MAP/SAP/ESAP: 0/19/71.5 % (i.e. 78.5 % of all deaths of TAP. ESAP 21 p., FAP 6 p., SFAP 15 p. FAP/SFAP: M/F 3/3 or 11/4, age 44.5 (17-81) or 46.8 (25-73). FAP etiology: 1x biliary, 1x alcohol, 4x ?; SFAP: 6x biliary, 5x alcohol, 4x ?. FAP: 4x severe hypercholesterolemia or hypertriglyceridemia, SFAP dtto 3x. FAP lethality: 83%, SFAP: 67%. Mean survival rate: FAP 4.1 d., SAP 9.2 d. FAP treatment: conservative 3 p., surgical 3 p., hemoelimination 2 p. SFAP treatment: conservative 9 p., surgical 6 p (reoperated 92% of all surgically treated, 7x on average), hemoelimination 8 p.

Discussion:
Mortality prediction especially in FAP and SAP – progression and early occurrence of organ failure and its dynamics, existence of organ failure at the time of patient’s admission and its rapid deterioration. Action of age, comorbidity and aetiology: insufficient data for meta-analysis; difference between ESAP and LAP has no statistic importance. Indigenous set of patients proves incidence, progression and lethality in FAP and SFAP, demonstrates higher incidence of hyperlididemia and hypercholesterolemia in FAP (60%) compared to SFAP with far more frequent biliary or alcohol aetiology. Among FAP, SAP and LSAP no age-dependent differences were proved. Absolute dominance of organ failure symptoms, suspicion to infected necrosis rather rarely expressed. Differences in prognosis in relation to applied treatment – either conservative or surgical (FAP surgery 50%, SFAP surgery 60%) were not observed. In section severe destructive findings in pancreas and its vicinity as well as extensive organ lesions were observed.

Conclusion:
Our own results are in concord with the results of other studies. It appears pretty useful to search for further ESAP predicting factors within meta-analytical studies. Intensive resuscitation care since the admission is a necessity, despite that, particularly in FAP, the results are unfavourable; surgical treatment has higher impact in SFAP than in AP, where often is ultimum refugium only.

Key words:
acute pancreatitis – fulminant acute pancreatitis

Zdroje

1. Werner, J., et al. Management of acute pancreatitis: from surgery to interventional intensive care. Gut, 2005, 54, 426–436.

2. Secknus, R., Mossner, J. Incidenz und Prevalenz Veranderungen der akuten und chronischen Pankreatitis. Chirurg, 2000, 71, 249–252.

3. Gurusamy, K. S., Farouk, M., Tweedie, J. H. UK guidelines for the management of acute pancreatitis. Gut, 2005, 54(9): 1344–1345.

4. Takada, T., et al. JPN Guidelines for the management of acute pancreatitis. J. Hepatobiliary Pancreat. Surg., 2006; 13(1): 2–60.

5. Uhl, W., et al. IAP guidelines for the surgical management of acute pancreatitis. Pancreatology, 2002, 2, 565–573.

6. Bradley, E. L. A clinically based classification system for acute pancreatitis.Summary of the International symposium on acute pancreatitis. Arch. Surg., Atlanta, 1992, 1993, 128, 586–590.

7. Osingol, S. L., et al. . Klin. Khir., 1982, 11, 38–40.

8. Kivilaakso, E., et al. Resection of the pancreas for acute fulminant pancreatitis. Surg. Gynecol. Obstet, 1981, 152(4): 493–498.

9. Sharma, M., Banerjee, D., Garg, P. K. Characterization of newer subgroups of fulminat and subfulminant pancreatitis associated with a high early mortality. Am. J. Gastroenterol., 2007, 102(12): 2688–2695.

10. Lilja, H. E., et al. Utilization of intenzive care unit resources in severe acute pancreatitis. JOP, 2008, 8, 9(2), 179–184.

11. Werner, J. Fulminant pancreatitis – surgical point of view. Praxis, 2006, 95(48), 187–189.

12. Kong, L., et al. Clinical characteristics and prognostic factors of severe acute pancreatitis. World J. Gastroenterol., 2004, 10(22), 3336–3338.

13. Adler, G. Fulminant pancreatitis – internal point of view. Praxis, 2006, 95(48), 1882–1886.

14. Carnoval, A., et al. Mortality in acute pancreatitis: is it an early or a late event? JOP, 2005, 6(5), 438–444.

15. Beger, H. G., Rau, B. M. Severe acute pancreatitis: Clinical course and management. World J. Gastroenterol., 2007, 13(38), 5043–5051.

16. Isenmann, R., Rau, B., Beger, H. G. Early severe acute pancreatitis: characteristics of a new subgroup. Pancreas, 2001, 22(3), 274–278.

17. Gloor, B., et al. Late mortality in patiens with severe acute pancreatitis. Br. J. Surg., 2001, 88, 274–278.

18. Bosscha, K. et al. Fulminant acute pancreatitis and infected necrosis: results of open management of the abdomen and „planned“ reoperations. J. Am. Coll. Surg., 1998, 187(3), 255–262.

19. Kaufmann, P., et al. Intensive care management of acute pancreatitis: recognition of patiens at high risk of developing severe or fatal complications. Wien Klin. Wochenschr., 1996, 108(1), 9–15.

20. Sun, Z. X., Juany, H. R., Zhou, H. Indwelling catheter and konservative measures in the treatment of abdominal compartment syndrome in fulminant acute pancreatitis. World J. Gastroenterol., 2006, 12(31), 5068–5070.

21. Mofidi, R., et al. Association of early systematic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br. J. Surg., 2006, 93, 738–744.

22. Talamini, G., et al. Risk of death from acute pancreatitis. Int. J. Pancreatol., 1996, 16, 15–24.

23. Garg, P. K., et al. Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis. Clin. Gastroenterol. Hepatol., 2005, 3, 159–166.

24. Bhattacharya, S., et al. Severe acute pancreatitis : Clinical course and management. World J. Gastroenterol., 2007, 13(38), 504–5051.

25. Halonen, K. I., et al. Predicting fatal outcome in the early phase of severe acute pancreatitis by using novel prognostic models. Pancreatology, 2003, 3(4), 309–315.