Severe acute pancreatitis: when to be concerned?

Abstract

The fate of a patient with acute pancreatitis largely depends on early recognition of the severity of the disease. Acute pancreatitis is severe when organ failure and/or pancreatic necrosis occur. Whereas simple and low cost parameters are available for the detection of organ failure, the detection and extent of pancreatic necrosis requires a costly contrast-enhanced computed tomography. This is not always available in all institutions. This review article which considers when the clinician should be concerned about his patient diagnosed with acute pancreatitis, summarizes possibilities for diagnosing clinical severe (that is organ failure) and radiological severe (that is the necrotizing form of the disease) pancreatitis using simple and inexpensive parameters which are available everywhere. At present, a CT scan should be performed in those patients with alcohol etiology, those admitted to hospital early (time interval between the onset of symptoms and admission to hospital of less than 24 h, those presenting with rebound tenderness and/or guarding, a lipase >1,000 U/l, as well as a raised hematocrit and blood glucose. The evaluation, furthermore, shows that some parameters have a sufficiently high negative predictive value of >90%, which may render a contrast-enhanced CT scan unnecessary in the early stages, unless the patient fails to improve. These parameters include non-alcohol etiology, time interval between onset and admission to hospital longer than 24 h, no guarding or rebound tenderness on admission, low or normal hematocrit and nonelevated blood glucose. It is necessary to look further on simple low cost and more valid parameters on admission in order to reliably distinguish between necrotizing pancreatitis and interstitial pancreatitis.