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Pancreatitis

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Written by Neville Dastur   
Wednesday, 06 April 2005 20:38

Pancreatitis

Defined as a inflammatory disorder of the pancreas characterised by abdominal pain radiating to the back that is self perpetuating.

 

Aetiology

G Gallstones
E Ethanol
T Trauma
S Steroids
M Mumps
A Autoimmune (PAN)
S Scorpion bites
H Hyper lipidaemia / calcaemia Hypothermia
E ERCP
D Drugs (Steroids / Thiazide diuretics / Azathioprine)
Alternative classification:
Obstruction - GS / tumour / congenital
Drugs / Toxins - EtOH / Recreational Drugs
Iatrogenic - ERCP / CABG / Blunt trauma (rare)
Metabolic - as on left Idiopathic - 10% no cause can be found but often ends up being microlithiasis.
  • Opie (1901) first described relationship between GS and pancreatitis. Suggested obstruction leading to reflux and activation of enzymes within the gland.
  • The key event is probably activation of trypsin above that of intrinsic antitrypsin activity.
  • The precise mechanism of injury remains uncertain.

Diagnosis

  • Sudden onset abdominal pain radiating to back.
  • Often associated with nausea and vomiting.
  • Cutaneous extravasated blood - Grey Turner's sign (into flanks) / Cullen's sign (umbilicus)
  • O/E abdomen can be rigid (peritonitic)
  • Serum Amylase > 1200 i.u. / ml (not a marker of severity)
Other cause of amylase > 1000
Perforated peptic ulcer
Perforated GB
Ruptured AAA
Ruptured ectopic
Mesenteric infarct
Afferent loop obstruction following gastrectomy

Treatment

  • Oxygen
  • Fluids, fluids and fluids
  • Analgesia
  • NBM
  • Anti-thombotic measures
  • Depending on severity
    • Urinary catheter
    • NG Tube
    • Antibiotics
    • CVP line
    • TPN / Jejunal feeding
    • Rarely surgery
  • Peritoneal lavage is of dubious value
  • Early ERCP

 

Age > 55yrs Fall in haematocrit > 10%
WBC > 16 x 109 / l Urea rise > 10 mmol / l
Glucose > 11 mmol / l Serum Ca2+ < 2mmol/l
LDH > 350 i.u. / l PaO2 < 8kPa
AST > 60 i.u. / l Est. Fluid sequestration > 6 litres
Overall mortality is 10%!!
0-2 = mortality 2%
3-4 = mortality 15%
5-6 = mortality 40%
7-8 = approaching 100%

 

Complications

  • Systemic
  • Pulmonary failure from ARDS / pneumonia
  • Cardiovascular collapse from the fluid shifts
  • Renal failure
  • Abdominal
    • Pancreatic necrosis and infection
    • Pseudocysts and pancreatic abscess
  • Late
    • Diabetes mellitus
    • Malabsorption (rare)
 

Comments  

 
+4 # Guest 2005-06-06 09:15
P = Pain killer
A = Antibiotics in severe cases
N = Nasogastric intubation in acute cases
C = CVP line in severe cases
R = Resuscitation with Fluids
E = Electrolytes balance
A = Arterial Blood Gas analysis
S = Surgical intervention
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-3 # Guest 2005-06-06 21:51
Thanks, thats a nice addition ;-)
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# Guest 2005-08-08 14:57
pancreatitis mnemonics;
the fatter the worse the course
ranson\'s eleven=ocean\'s eleven
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-3 # Guest 2005-09-11 23:43
please add to this tutorial classification&diagnostic features of each when classified seprately
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-1 # Guest 2006-02-06 17:50
:-x
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+2 # Guest 2006-04-15 11:08
dear doctors ; view slide show at thsi site \"what surgeons should know baout pnacreatitis
Medindia-Download / View SlidesDr. Fiaz M.Fazili Contact Author, 6/22/2005 5:46:10 AM. 14. urinary infection in children & vesico ureteric reflux. Dr.Ramesh Babu Contact Author, 2/8/2004 ...
www.medindia.net/slides/download. asp?name=&service=&page=2&startpage=1
Dr Fiaz Maqbool Fazili MbBBS;MS;MAMs; FICA:FICS(USA)Surgeo n KFH medinah
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-3 # Guest 2006-04-15 13:04
World\'s Largest Medical Academic Website. Journals, Congresses ...... 86k. Acute Necrotizing Pancreatitis, Fiaz Maqbool Fazili, MD, 356k. ... 86k. Acute Necrotizing Pancreatitis, Fiaz Maqbool Fazili, MD, 356k. ...
www.muratalper.com/linkler/hematosunum.asp - 97k - Supplemental Result
dr Fiaz Fazili
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+2 # Guest 2006-04-25 15:35
Investigations
Blood Investigations - Full blood count, Renal function tests, Liver Function, serum calcium, serum amylase and lipase, Arterial blood gas
Imaging - Chest Xray (for exclusion of perforated viscus), Abdominal Xrays (for detection of \"sentinel loop\" dilated duodenum sign, and gallstones which are radioopaque in 10 %) and CT abdomen
[edit]
Amylase and lipase
Serum amylase rises 2 to 12 hours from the onset of symptoms, and normalises within 1 week
Serum lipase rises 4 to 8 hours from the onset of symptoms and normalises within 8 to 14 days.
Serum amylase may be normal (in 10 % of cases) for cases of acute on chronic pancreatitis (depleted acinar cell mass) and hypertriglyceridemia
Reasons for false positive elevated serum amylase include salivary gland disease (elevated salivary amylase) and macroamylasemia
If Lipase level is about 2.5 to 3 times that of Amylase, it is an indication of pancreatitis due to Alcohol[1].
[edit]
CT abdomen
CT abdomen should not be performed before the 1st 48 hours of onset of symptoms as early CT (
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+2 # Guest 2006-04-25 15:39
CT abdomen
CT abdomen should not be performed before the 1st 48 hours of onset of symptoms as early CT (
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-2 # Guest 2006-10-12 15:33
CT Findings can be classified into the following categories for easy recall :

Intrapancreatic - diffuse or segmental enlargement, edema, gas bubbles, pancreatic pseudocysts and phlegmons/abscesses (which present 4 to 6 wks after initial onset)
Peripancreatic / extrapancreatic - irregular pancreatic outline, obliterated peripancreatic fat, retroperitoneal edema, fluid in the lessar sac, fluid in the left anterior pararenal space
Locoregional - Gerota's fascia sign (thickening of inflamed Gerota's fascia, which becomes visible), pancreatic ascites, pleural effusion (seen on basal cuts of the pleural cavity), adynamic ileus,
[edit]
Balthazar scoring
Balthazar Scoring for the Grading of Acute Pancreatitis

Grade A - normal CT
Grade B - focal or diffuse enlargement of the pancreas
Grade C - pancreatic gland abnormalities and peripancreatic inflammation
Grade D - fluid collection in a single location
Grade E - two or more collections and/or gas bubbles in or adjacent to pancreas
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-2 # Guest 2006-10-12 16:12
SCORING SYSTEMS – Despite the proliferation of scoring systems for grading acute pancreatitis, none is ideal. In many studies, clinical assessment for severe pancreatitis (looking for signs of peritonitis, shock, or respiratory distress) was as accurate as most scoring systems. However, routine clinical assessment identifies only 34 to 44 percent of patients with severe acute pancreatitis . With the exception of the APACHE II system ,the other systems (eg, Ranson, Glasgow, Banks, and Agarwal and Pitchumoni take 48 hours to complete, can be used only once, and do not have a high degree of sensitivity and specificity Furthermore, some have limited utility since they focus on specific complications to be prevented (eg, Banks) or are invasive (eg, Leeds diagnostic peritoneal lavage) [and are therefore uncommonly used.
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+1 # Guest 2006-10-12 16:14
Scoring systems have been designed to categorize levels of risk in populations, allowing comparison of different series. However, they can not identify accurately the risk that an individual patient will develop a complication The most widely used systems at the present time are Ranson's, APACHE II, and Balthazar's.Atlanta
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+1 # Guest 2006-10-12 16:16
Surgery INDICATIONS
Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii)complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria

Gas bubbles on CT scan (present in 20 to 50 % of infected necrosis)
Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas.
Surgical options for infected necrosis include:

Conventional management - necrosectomy with simple drainage
Closed management - necrosectomy with closed continuous lavage
Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)
[edit]
Complications
Complications can be systemic or locoregional.

Systemic complications include ARDS, multiple organ dysfunction syndrome, DIC, hypocalcemia (from fat saponification), hyperglycemia and insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
Locoregional complications include pancreatic pseudocyst and phelgmon / abscess formation, splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, thrombosis of the splenic vein, superior mesenteric vein and portal veins (in descending order of frequency), duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis
ComplicationsSurgery Indications
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+2 # Guest 2006-10-12 16:19
In acute gallstone pancreatitis, the ideal point in time for laparoscopic cholecystectomy with special reference to the severity of the disease has been prospectively analyzed. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for biliary acute pancreatitis. In mild disease, this is performed safely within 7 days, whereas in severe disease, especially in extended pancreatic necrosis, at least 3 weeks should elapse because of an increased infection risk.
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0 # Guest 2006-10-12 16:23
Patients of acute necrotising pancreatitis are usually very sick with single or multiple organ dysfunction. Most have a Ranson's score of more than 3 and APACHE II score of more than 8. They are usually managed in the intensive care or therapy units with majority of them requiring ventilation. As mentioned earlier, roughly 20% patients of acute pancreatitis will develop necrosis with a mortality rate exceeding 80%.Management and monitoring of this group must therefore be more intensive.

The general guidelines for management include the following [
• General Management

• Confirmation of diagnosis

• Prevention of infection

• Nutritional Support

• Monitoring of complicationsGeneral mangement
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+1 # Guest 2006-10-12 16:25
Types of Surgical Procedures

The choice of procedure is determined by the duration from onset, the degree of organ dysfunction and the position of the necrotic material within the abdomen.Current surgical practice in necrotising pancreatitis involves necrosectomy of the devitalized pancreatic and peripancreatic tissues.
There are three main types of surgical debridement. [1. Conventional drainage.

2. Open or semi-open procedure.

3. Closed procedure.
Conventional drainage involves necrosectomy with placement of standard surgical drains and re-operation as required by clinical criteria or lack of improvement according to imaging studies.[
Open or semi-open (laparostomy) management involves necrosectomy and either scheduled repeated laparotomies or open packing that leaves the abdominal wound exposed for frequent changes of dressing
Closed management involves necrosectomy with extensive intraoperative lavage of the pancreatic bed. The abdomen is closed over large bore drains for continuous high volume postoperative lavage of the lesser sac
Comparison of the results of conventional, open/semi open (laparostomy) and closed techniques from published series showed collective mortality rates as 42%, 20% and 21% respectively indicating a superiority for necrosectomy followed by re-exploration or continuous lavage. Studies comparing conventional relaparotomy with laparostomy after necrosectomy for pancreatic necrosis offer no difference in terms of morbidity and mortality
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+1 # Guest 2006-10-12 16:27
Complications of Necrosectomy

Necrosectomy by any of the above-mentioned techniques is always attended by postoperative complications. It is also to be understood that most of these patients will require multiple laparotomies and debridement of necrotic tissues along with drainage of intra-abdominal or retroperitoneal collections.
The usual attendant local complications are intra-abdominal and retroperitoneal collections, bleeding from pancreatic bed, pancreatic fistulas, small bowel and colonic fistulas. Pancreatic and gastrointestinal fistulas occur in about 40% of patients following necrosectomy and often require additional surgery for closure.] The mortality from debridement with open or closed techniques is approximately 20%.
Necrotising pancreatitis also has prominent effects on long- term pancreatic exocrine and endocrine function in about 50% of patients, but most preserve a good overall functional status. The development of pancreatic insufficiency varies with the extent of pancreatic parenchymal necrosis,
(ref-subratrau)
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+2 # Fiaz Maqbool Fazili 2008-04-07 21:15
Causes of hyperlipasemia (high lipase levels) may include:

Pancreatitis - also known as inflammation of the pancreas, can cause amylase and lipase levels to be increased up to 3 times normal. Both values should be increased, in order to carry the diagnosis of pancreatitis.
Lipase may be increased in tumors of the pancreas, or stomach certain stomach conditions. These conditions are usually painful.
Gall bladder infection - Inflammation of the gall bladder (cholecystitis), may cause increased lipase levels (hyperlipasemia).
Kidney failure can cause hyperlipasemia.
Your doctor or healthcare provider will diagnose hyperlipasemia by drawing a tube of blood. If there is a suspicion of gall bladder, pancreas or kidney problems, an ultrasound of the gall bladder or pancreas, or a CAT scan of your abdomen, may also be performed.
You may be at risk for pancreatitis if you are:
Extremely overweight (obese)
Have high triglyceride levels in your blood
Drink too much alcohol
Have been diagnosed with gall bladder stones (which may block the flow of secretions from the pancreas to the intestines)
Or have a family history of pancreatitis
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+3 # Fiaz Maqbool Fazili 2008-04-07 21:20
MAJOR RECOMMENDATIONS

ACR Appropriateness Criteria®

Clinical Condition: Acute Pancreatitis

Variant 1: Etiology unknown, first episode of pancreatitis.
Radiologic Exam Procedure Appropriateness Rating Comments
US, abdomen 8
CT, abdomen 6 With or without contrast
MRI, abdomen, with contrast 6
MRI, abdomen, MRCP 6
US, abdomen, endoscopic 5
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 2: Severe abdominal pain, elevated amylase lipase, no fever or evidence of fluid loss at admission; clinical score pending.
Radiologic Exam Procedure Appropriateness Rating Comments
US, abdomen 8
CT, abdomen 7 With or without contrast
MRI, abdomen, MRCP 7
MRI, abdomen, with contrast 6
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 3: Severe abdominal pain, elevated amylase lipase, 48 hours later assuming no improvement or degradation (assume no prior imaging).
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 8 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 4: Severe abdominal pain, elevated amylase lipase, fever and elevated white blood cell count.
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 9 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 5: Severe abdominal pain, elevated amylase lipase, hemoconcentration, oliguria, tachycardia.
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 9 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

This document focuses on the diagnosis and initial evaluation of patients with suspected or known acute pancreatitis. It does not address interventional procedures or documentation of complications such as abscess, pseudocyst, or pseudoaneurysm.

Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations of acute pancreatitis. Fluid collections associated with acute pancreatitis usually resolve spontaneously. Pancreatic pseudocysts are fluid collections that persist for 6 weeks or more. Pancreatic abscess is usually a complication of necrotizing pancreatitis, typically developing after 3 to 5 weeks. Determinants of the natural course of acute pancreatitis are pancreatic parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis, biologically active compounds in pancreatic ascites, and infection of necrosis. Early in the course of acute pancreatitis, multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. Late in the course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications.

The infection of pancreatic necrosis occurs in 8%-12% of acute pancreatitis patients and in 30 to 40% of patients with necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of the gland, peripancreatic inflammation with or without fluid, solitary or loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent infection in any of the above sites of inflammation. Distant organ complications can lead to organ failure, protracted course, and death. Prediction of which patients will develop these complications is achieved through clinical scoring systems and imaging findings. Choice of scoring system is beyond the scope of these recommendations.

Acute pancreatitis is suspected in patients presenting with epigastric upper abdominal pain that is acute in onset, rapidly increasing in severity, and persistent without relief. The intensity of the pain almost always results in the patient seeking medical attention. Differential diagnosis includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary colic, and myocardial infarction. Serum amylase and/or lipase levels can be considered diagnostic when the reported value(s) is >3 times normal. Lipase levels are more specific for acute pancreatitis, as hyperamylasemia may be present in a variety of conditions. Of note is that serum enzyme levels do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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0 # Fiaz Maqbool Fazili 2008-04-07 21:21
MAJOR RECOMMENDATIONS

ACR Appropriateness Criteria®

Clinical Condition: Acute Pancreatitis

Variant 1: Etiology unknown, first episode of pancreatitis.
Radiologic Exam Procedure Appropriateness Rating Comments
US, abdomen 8
CT, abdomen 6 With or without contrast
MRI, abdomen, with contrast 6
MRI, abdomen, MRCP 6
US, abdomen, endoscopic 5
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 2: Severe abdominal pain, elevated amylase lipase, no fever or evidence of fluid loss at admission; clinical score pending.
Radiologic Exam Procedure Appropriateness Rating Comments
US, abdomen 8
CT, abdomen 7 With or without contrast
MRI, abdomen, MRCP 7
MRI, abdomen, with contrast 6
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 3: Severe abdominal pain, elevated amylase lipase, 48 hours later assuming no improvement or degradation (assume no prior imaging).
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 8 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 4: Severe abdominal pain, elevated amylase lipase, fever and elevated white blood cell count.
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 9 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.

Variant 5: Severe abdominal pain, elevated amylase lipase, hemoconcentration, oliguria, tachycardia.
Radiologic Exam Procedure Appropriateness Rating Comments
CT, abdomen 9 With or without contrast
US, abdomen 7
MRI, abdomen, with contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in the tables are listed at the end of the \"Major Recommendations\" field.
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+1 # Fiaz Maqbool Fazili 2008-04-07 21:22
This document focuses on the diagnosis and initial evaluation of patients with suspected or known acute pancreatitis. It does not address interventional procedures or documentation of complications such as abscess, pseudocyst, or pseudoaneurysm.

Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations of acute pancreatitis. Fluid collections associated with acute pancreatitis usually resolve spontaneously. Pancreatic pseudocysts are fluid collections that persist for 6 weeks or more. Pancreatic abscess is usually a complication of necrotizing pancreatitis, typically developing after 3 to 5 weeks. Determinants of the natural course of acute pancreatitis are pancreatic parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis, biologically active compounds in pancreatic ascites, and infection of necrosis. Early in the course of acute pancreatitis, multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. Late in the course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications.

The infection of pancreatic necrosis occurs in 8%-12% of acute pancreatitis patients and in 30 to 40% of patients with necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of the gland, peripancreatic inflammation with or without fluid, solitary or loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent infection in any of the above sites of inflammation. Distant organ complications can lead to organ failure, protracted course, and death. Prediction of which patients will develop these complications is achieved through clinical scoring systems and imaging findings. Choice of scoring system is beyond the scope of these recommendations.

Acute pancreatitis is suspected in patients presenting with epigastric upper abdominal pain that is acute in onset, rapidly increasing in severity, and persistent without relief. The intensity of the pain almost always results in the patient seeking medical attention. Differential diagnosis includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary colic, and myocardial infarction. Serum amylase and/or lipase levels can be considered diagnostic when the reported value(s) is >3 times normal. Lipase levels are more specific for acute pancreatitis, as hyperamylasemia may be present in a variety of conditions. Of note is that serum enzyme levels do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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0 # Fiaz Maqbool Fazili 2008-04-07 21:24
his document focuses on the diagnosis and initial evaluation of patients with suspected or known acute pancreatitis. It does not address interventional procedures or documentation of complications such as abscess, pseudocyst, or pseudoaneurysm.

Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations of acute pancreatitis. Fluid collections associated with acute pancreatitis usually resolve spontaneously. Pancreatic pseudocysts are fluid collections that persist for 6 weeks or more. Pancreatic abscess is usually a complication of necrotizing pancreatitis, typically developing after 3 to 5 weeks. Determinants of the natural course of acute pancreatitis are mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. Late in the course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications.

The infection of pancreatic necrosis occurs in 8%-12% of acute pancreatitis patients and in 30 to 40% of patients with necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of the gland, peripancreatic inflammation with or without fluid, solitary or loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent infection in any of the above sites of inflammation. Distant organ complications can lead to organ failure, protracted course, and death. Prediction of which patients will develop these complications is achieved through clinical scoring systems and imaging findings. Choice of scoring system is beyond the scope of these recommendations.

Acute pancreatitis is suspected in patients presenting with epigastric upper abdominal pain that is acute in onset, rapidly increasing in severity, and persistent without relief. The intensity of the pain almost always results in the patient seeking medical attention. Differential diagnosis includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary colic, and myocardial infarction. Serum amylase and/or lipase levels can be considered diagnostic when the reported value(s) is >3 times normal. Lipase levels are more specific for acute pancreatitis, as hyperamylasemia may be present in a variety of conditions. Of note is that serum enzyme levels do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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0 # Fiaz Maqbool Fazili 2008-04-07 21:30
Determinants of the natural course of acute pancreatitis are pancreatic parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis, biologically active compounds in pancreatic ascites, and infection of necrosis. Early in the course of acute pancreatitis, multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. Late in the course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications.

The infection of pancreatic necrosis occurs in 8%-12% of acute pancreatitis patients and in 30 to 40% of patients with necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of the gland, peripancreatic inflammation with or without fluid, solitary or loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent infection in any of the above sites of inflammation. Distant organ complications can lead to organ failure, protracted course, and death. Prediction of which patients will develop these complications is achieved through clinical scoring systems and imaging findings. Choice of scoring system is beyond the scope of these recommendations.

Acute pancreatitis is suspected in patients presenting with epigastric upper abdominal pain that is acute in onset, rapidly increasing in severity, and persistent without relief. The intensity of the pain almost always results in the patient seeking medical attention. Differential diagnosis includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary colic, and myocardial infarction. Serum amylase and/or lipase levels can be considered diagnostic when the reported value(s) is >3 times normal. Lipase levels are more specific for acute pancreatitis, as hyperamylasemia may be present in a variety of conditions. Of note is that serum enzyme levels do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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0 # Fiaz Maqbool Fazili 2008-04-07 21:33
in any of the above sites of inflammation. Distant organ complications can lead to organ failure, protracted course, and death. Prediction of which patients will develop these complications is achieved through clinical scoring systems and imaging findings. Choice of scoring system is beyond the scope of these recommendations.

Acute pancreatitis is suspected in patients presenting with epigastric upper abdominal pain that is acute in onset, rapidly increasing in severity, and persistent without relief. The intensity of the pain almost always results in the patient seeking medical attention. Differential diagnosis includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary colic, and myocardial infarction. Serum amylase and/or lipase levels can be considered diagnostic when the reported value(s) is >3 times normal. Lipase levels are more specific for acute pancreatitis, as hyperamylasemia may be present in a variety of conditions. Of note is that serum enzyme levels do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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0 # Fiaz Maqbool Fazili 2008-04-07 21:35
do not correlate with the severity of the disease. Consequently, clinical scoring systems and imaging tests have been advocated to classify individual patients. Furthermore, the diagnosis may be overlooked in the absence of typical enzyme elevation. In some patients, acute pancreatitis may be present in the absence of enzyme abnormalities.

Imaging tests available for the diagnosis of acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT scanning, MRI, and MRCP. Imaging tests are performed for various reasons, including detection of gallstones, detection of biliary obstruction, diagnosis of pancreatitis when the clinical situation is unclear, identification of patients with high-risk pancreatitis, and detection of complications of pancreatitis.

US to detect gallbladder stones should be performed in every patient with acute pancreatitis, even alcoholics. US is also effective in diagnosing biliary obstruction, which, when present, often prompts endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.

Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.

Abbreviations

* CT, computed tomography
* MRI, magnetic resonance imaging
* MRCP, magnetic resonance cholangiopancreatogr aphy
* US, ultrasound
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+1 # Fiaz Maqbool Fazili 2008-04-07 21:36
endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction. US is less successful in diagnosing choledocholithiasis and has limited applications in the early staging of the disease. Visualization of the pancreas is often impaired because of overlying bowel gas, and the detection of intraparenchymal and retroperitoneal fluid collections correlates poorly with pancreatic necrosis. US with color Doppler is useful to detect venous complications of acute pancreatitis. In patients with suspected acute gallstone pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a definite diagnosis and to investigate the etiology. EUS is useful, when needed clinically, to detect common duct stones when initial studies are negative. It can often determine an etiology (usually biliary) in patients initially diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones.
Reply | Reply with quote | Quote
 
 
+1 # Fiaz Maqbool Fazili 2008-04-07 21:37
CT is an insensitive detector of biliary calculi, but is superb in delineating the pancreas and acute pancreatitis-associated abnormalities. CT scanning provides clear images of the pancreas and adjacent structures and allows for the differentiation of acute pancreatitis from other abdominal diseases. CT findings helpful for diagnosing acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the inflammatory changes around the pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a much longer time to scan the pancreas in comparison with CT. MRCP has a high accuracy in detecting bile duct stones
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-1 # Fiaz Maqbool Fazili 2008-04-07 21:37
Physiologically based scoring systems such as the APACHE II and Ranson\'s criteria are designed to identify early prognostic signs that predict severity of clinical course in an individual patient. In 1985, one study showed that although clinical scoring systems were highly correlated with increasing CT severity, disease severity was sometimes underestimated by clinical scoring alone. The key criterion for identifying patients at higher risk for fatal pancreatitis is the presence of pancreatic necrosis. The scoring system was revised in 1990 to account for the significance of pancreatic necrosis, and the CT severity index was created. The utility of the Ranson\'s criteria compared with that of the CT severity index (the Balthazar CT severity index) for predicting the necessity for admission to an intensive care unit in patients with acute pancreatitis was analyzed in a recent study. The Balthazar CT severity index correlated highly with the overall occurrence of complications (r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.
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0 # Fiaz Maqbool Fazili 2008-04-07 21:38
the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better prognostic indicator than the Ranson criteria for complications and mortality. A modified CT severity index, which simplifies the evaluation of pancreatic necrosis, inflammatory changes, and extrapancreatic complications, has also been proposed. There are isolated reports of clinical scoring systems yielding equivalent or superior results to imaging tests. However, it also should be remembered that most clinical systems require a second assessment within 48 hours to monitor progression or stability, as opposed to relatively instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI can both be used to assess pancreatic necrosis and evaluate peripancreatic inflammation and fluid collections. MRI is particularly useful in patients who cannot receive iodinated contrast material due to prior adverse contrast reaction or renal insufficiency. Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.
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0 # Fiaz Maqbool Fazili 2008-04-07 21:39
Furthermore, the integrity of the pancreatic duct can be assessed by means of MRCP in an MRI study; this is important, since in previous studies pancreatic duct rupture was reported in about 30% patients with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance on images obtained following intravenous contrast administration. These unenhanced areas have been proved to represent necrotic regions when correlated with findings at pancreatic debridement. While some have suggested that the site of necrosis within the pancreas may further predict outcome, others have found no such correlation. The presence of peripancreatic fluid collections is usually associated with severe disease. Echo-enhanced US has been recently reported as a new initial imaging approach; it can be used as an alternative in patients in whom both CT and MRI are contraindicated.

Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients.
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0 # Fiaz Maqbool Fazili 2008-04-07 21:40
Controversy has emerged because of the observation that intravenous contrast impairs the microcirculation of the pancreas in rats with acute necrotizing pancreatitis and may increase the severity of the disease. These results could not be reproduced in the opossum. No prospective human trials have been published to date. Most experts believe the benefits of detecting necrosis outweigh any potential risk.

No objective clinical selection criteria exist that can determine which patients should have CT to assess the risk of severe pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is unclear. In patients with known acute pancreatitis, however, CT is reserved for patients with clinical, biochemical, or physiologic indications of severe disease. There is no information suggesting that routine CT in patients with milder disease (low APACHE II or Ranson scores) would result in upstaging a significant number of patients
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0 # Fiaz Maqbool Fazili 2009-04-12 18:20
BISAP-Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome,
Current methods of risk stratification in AP have important limitations;Current methods of risk stratification in AP have important limitations.
The Ranson and modified Glasgow score contain data not routinely collected at the time of hospitalization.
Both require 48 h to complete, missing a potentially valuable early therapeutic window.
The most commonly utilised prediction scoring system for clinical research studies in AP is the Acute Physiology and Chronic Health Examination (APACHE) II.A new mortality-based prognostic scoring system for use in acute pancreatitis may help identify patients at increased risk for in-hospital morta
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0 # Fiaz Maqbool Fazili 2009-04-12 18:21
BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality.
5 variables identified that predicted in-hospital mortality, each of which is assigned 1 point if present during the first 24 hours:
B_blood urea nitrogen more than 25 mg/dL,
I_impaired mental status,
S_systemic inflammatory response syndrome,
A_age older than 60 years
P_pleural effusion.
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0 # Fiaz Maqbool Fazili 2009-04-12 18:22
Following candidate risk factors in model development:
Individual Ranson signs: age, white blood cell (WBC) count, glucose, aspartate aminotransferase (AST), blood urea nitrogen (BUN), lactate dehydrogenase (LDH) and serum calcium.
Pleural effusion(on chest radiography or CT).
The Systemic inflammatory response syndrome (SIRS) defined by the presence of 2 of the following criteria:
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0 # Fiaz Maqbool Fazili 2009-04-12 18:23
Haemoconcentration (haemoglobin is included as a continuous variable)
Atlanta Symposium criteria for organ failure systolic blood pressure, creatinine, partial pressure of arterial oxygen (PaO2).
Altered mental status; defined as any record of disorientation, lethargy somnolence, coma or stupor in the medical record.
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0 # Fiaz Maqbool Fazili 2009-04-12 18:24
Each point on the BISAP score was worth 1 point. There was a steady increase in the risk for mortality with an increasing number of points:
0 point: observed mortality rate of 0.1%
1 point: observed mortality rate of 0.4%
2 points: observed mortality rate of 1.6%
3 points: observed mortality rate of 3.6%
4 points: observed mortality rate of 7.4%
5 points: observed mortality rate of 9.5%
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0 # Fiaz Maqbool Fazili 2009-04-12 18:25
Studies available presently on BISAP show
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0 # Fiaz Maqbool Fazili 2009-04-12 18:26
The ability to risk-stratify patients early in their disease course has several important implications.
Early identification of high-risk patients may alert doctors to institute aggressive resuscitation efforts and to consider specialty care referral.
A severity index provides standardized criteria for enrolment of subjects into future clinical studies.
A population-based system of risk stratification provides an instrument for additional outcomes research.
For example, identification of factors associated with death among patients with low BISAP scores may help to lead to improvements in future management strategies in AP.
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0 # Fiaz Maqbool Fazili 2009-04-12 18:27
The BISAP score stratifies patients within the first 24 h of admission according to their risk of in-hospital mortality and was able to identify patients at increased risk of mortality prior to the onset of organ failure,\" the study authors conclude. \"The ability to risk-stratify patients early in their course is a major step to improving future management strategies in acute pancreatitis.\"Gut. 2009;57:1645-1646, 1698-1703
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