Early prediction and prevention of infected pancreatic necrosis

Abstract

Approximately 20%-30% of patients with acute necrotizing pancreatitis develop infected pancreatic necrosis (IPN), a highly morbid and potentially lethal complication. Early identification of patients at high risk of IPN may facilitate appropriate preventive measures to improve clinical outcomes. In the past two decades, several markers and predictive tools have been proposed and evaluated for this purpose. Conventional biomarkers like C-reactive protein, procalcitonin, lymphocyte count, interleukin-6, and interleukin-8, and newly developed biomarkers like angiopoietin-2 all showed significant association with IPN. On the other hand, scoring systems like the Acute Physiology and Chronic Health Evaluation II and Pancreatitis Activity Scoring System have also been tested, and the results showed that they may provide better accuracy. For early prevention of IPN, several new therapies were tested, including early enteral nutrition, antibiotics, probiotics, immune enhancement, etc., but the results varied. Taken together, several evidence-supported predictive markers and scoring systems are readily available for predicting IPN. However, effective treatments to reduce the incidence of IPN are still lacking apart from early enteral nutrition. In this editorial, we summarize evidence concerning early prediction and prevention of IPN, providing insights into future practice and study design. A more homogeneous patient population with reliable risk-stratification tools may help find effective treatments to reduce the risk of IPN, thereby achieving individualized treatment.

Keywords: Acute pancreatitis; Antibiotics; Biomarker; Immune enhancement therapy; Infected pancreatic necrosis; Nutrition therapy; Probiotics; Scoring system; Selective digestive decontamination.

Figure 1

Summary of evidence concerning early prediction and prevention of infected pancreatic necrosis. CRP: C-reactive protein; PCT: Procalcitonin; IL-6 and 8: Interleukins-6 and -8; Ang-2: Angiopoietin-2; ALC: Absolute lymphocyte count; APACHE II: Acute Physiology and Chronic Health Evaluation II; SIRS: systemic inflammatory response syndrome; PASS: Pancreatitis Activity Scoring System; mPASS: Modified Pancreatitis Activity Scoring System; EN: Enteral nutrition; PN: Parenteral nutrition; Tα1: Thymosin alpha 1.