Am Fam Physician. 2008 Mar 1;77(5):594.
to the editor: The authors of the article, “Acute Pancreatitis: Diagnosis, Prognosis, and Treatment,” in the May 15, 2007, issue of American Family Physician, raise excellent points.1 I would offer the following points for consideration:
A meta-analysis in 2004 concluded that obesity has prognostic significance for the development of systemic and local complications (e.g., necrosis, sepsis).2 This analysis was limited by the number of studies reviewed (four of the 12 identified through a Medline search). Nonetheless, the American College of Gastroenterology in its 2006 practice guideline for pancreatitis identifies obesity as a risk factor for severity of pancreatitis.3 Another study also found that obesity is an independent risk factor for severe acute pancreatitis.4
The presence of pleural effusion or infiltrate within the first 24 hours of admission has also been found to be suggestive of greater severity and, possibly, increased mortality.3 It may be useful, therefore, to obtain plain radiographs of the chest as part of the initial evaluation, and certainly in the event that hypoxemia is identified.
The authors include Ranson's criteria in their summary of severity assessment.1 However, one meta-analysis found that the positive predictive power of Ranson's criteria is no better than individual clinical judgment.5
The authors state that signs of organ failure within the first 24 hours of admission significantly increase the risk of death.1 However, the duration of organ failure may determine the risk of mortality. A study involving 290 patients reported that resolution of organ failure within 48 hours resulted in one mortality, whereas organ failure of greater duration resulted in 36 deaths and greater overall morbidity.6
Recent pancreatitis management guidelines identify serum hematocrit as one of the most useful values to evaluate at presentation and at 12 and 24 hours after admission as a marker of fluid resuscitation effectiveness.3 Specifically, it has been postulated that hemoconcentration may compromise pancreatic microcirculation, contributing to pancreatic necrosis.
REFERENCESshow all references
1. Carroll JK, Herrick B, Gipson T, Lee SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician. 2007;75(10):1513–1520....
2. Martinez J, Sanchez-Paya J, Palazon JM, Suazo-Barahona J, Robles-Diaz G, Perez-Mateo M. Is obesity a risk factor in acute pancreatitis? A meta-analysis. Pancreatology. 2004;4(1):42–48.
3. Banks PA, Freeman ML, for the Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101(10):2379–2400.
4. Papachristou GI, Papachristou DJ, Avula H, Slivka A, Whitcomb DC. Obesity increases the severity of acute pancreatitis: performance of APACHE-O score and correlation with the inflammatory response. Pancreatology. 2006;6(4):279–285.
5. De Bernardinis M, Violi V, Roncoroni L, Boselli AS, Giunta A, Peracchia A. Discriminant power and information content of Ranson's prognostic signs in acute pancreatitis: a meta-analytic study. Crit Care Med. 1999;27(10):2272–2283.
6. Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut. 2004;53(9):1340–1344.
editor's note: This letter was sent to the authors of “Acute Pancreatitis: Diagnosis, Prognosis, and Treatment,” who declined to reply.
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