Band 9, Heft 4

Acute pancreatitis is a common disease with a benign course in the majority of patients, but it is associated with serious morbidity, and mortality close to 20% in up to 20% of cases. The incidence of acute pancreatitis seems to be rising in western countries. About 75% of all cases are caused by gallstones or alcoholism. The relative rate of gallstones versus alcohol as etiology depends on the age and the area of enrolment. A thorough evaluation allows cause identification in another 10% of cases, leaving about 15–20% as idiopathic. The most common causes, and a growing list of less frequent and sometimes very rare and controversial etiologies, are reviewed in this article. A classification on the pathogenic mechanisms of causes of acute pancreatitis based is used in this Review. The approach, or suggested plan of investigations, to determine the etiology of acute pancreatitis, based on the most recently published Guidelines is outlined.

Until Atlanta Classification (AC) made in 1992, there was not any classification of acute pancreatitis (AP). Last twenty years AC let us compare results and papers. But the increasing understanding of the pathophysiology of AP, improvements in diagnostic methods and the development of minimally invasive tools for radiological, endoscopic and surgical management of local complications, several authors have called for the AC to be reviewed. Last months, two new classifications of AP have been published. We made a historical review of AC, the two new classifications and a comparison between them.

To evaluate the effectiveness of serum levels of resistin and CD14 expression in monocytes, and high-sensitivity C-reactive protein (hsCRP) in early stages of acute pancreatitis and correct prediction of the severity of acute pancreatitis (AP) using scoring systems. The study involved 10 (29.41%) male and 24 (70.59%) female patients (total n=34) followed for AP diagnosis at the Department of General Surgery, Ataturk University Medical School between July 2008 and September 2009. In all the patients, Ranson and APACHE II scores, serum resistin, hsCRP, and monocyte CD14 expression levels were determined. The patients were divided into two groups as mild and severe AP groups. A control group was formed and the intergroup comparisons were made. Values ≥ 3 based on the Ranson scoring scale and values ≥ 8 in APACHE II scoring scale were considered to indicate severe AP. Evaluations were based on the values obtained on the 1st and 7th days for serum resistin and hsCRP levels and monocyte CD 14 expression. In 17 (50%) patients, severe AP was determined. No statistically significant differences were found between the mean serum resistin levels of AP groups, while the difference for the same parameter between the mild and severe AP groups and the control group was statistically significant. In the severe AP group, the mean 1st day and 7th day serum hsCRP levels were statistically significantly higher. The CD14 expression in monocytes was similar in all the groups. Serum hsCRP concentrations and Ranson and APACHE II scores and serum resistin and hsCRP concentrations on the 1st day were positively correlated. Serum hsCRP measurement is effective in determining the severity of acute pancreatitis. Serum resistin measurement may be a useful early marker in determining the inflammatory response in AP. However, CD14 expression in monocytes was not found to be a useful marker in the diagnosis and prediction of the disease severity in AP patients.

Acute pancreatitis (AP) is a local inflammatory response with systemic effects and an adverse evolution in 20% of cases. Its mortality rate is 5–10% in sterile and 15–40% in infected pancreatic necrosis. Infection is widely accepted as the main reason of death in AP. The evidence to enable a recommendation about antibiotic prophylaxis against infection of pancreatic necrosis is conflicting and difficult to interpret. Up to date, there is no evidence that supports the routine use of antibiotic prophylaxis in patients with severe AP. Treatment on demand seems to be the better option, avoiding excessive treatment and selection of bacterial. In infected acute pancreatitis, antibiotics of choice are imipenem, meronem or tigecycline in patients allergic to beta-lactams. Also fluconazole must be given in determinate clinical situations.

We perform an update about nutritional measures that have been adopted in patients with acute pancreatitis (AP). The nutritional support is an essential part of treatment in AP. When the AP is mild or moderate, there is no doubt that is not necessary to use an artificial nutritional support, and it is recommended that oral nutritional support should begin as soon as possible. If the AP is severe, the best way to provide nutritional support is through enteral nutritional (EN) because it reduces infection, length of hospitalization and mortality rate. Parenteral nutrition (PN) should be used only when EN is Impossible. However, there is no scientific evidence for recommending the most optimal route necessary to administer this type of nutritional support; we seek to uncover whether this is by gastric or jejunal route and the proper formula to use. There is an international agreement that the nutritional support should begin quickly, within the first 24 and 72 hours of hospitalization. As conclusion, more research needs to be done concerning nutritional support in AP, and many questions are not been answered yet.

Open necrosectomy, the standard surgical treatment of infected pancreatic necrosis (IPN), presents a high rate of postoperative complications and an associated mortality of 20–60%. In the last decade various minimally invasive approaches (MIA) have been proposed for the treatment of IPN and the results seem to improve on those reported with open necrosectomy. These MIA include: percutaneous, retroperitoneal, endoscopic (endoluminal) and laparoscopic (transperitoneal). The adoption of the step-up approach in the management of severe acute pancreatitis (SAP) facilitates the implementation of MIA as the surgical treatment of choice in most cases. Since MIA require the expertise of radiologists, endoscopists and surgeons, patients suffering SAP should be treated by multidisciplinary teams in referral centers. We describe the MIA currently available and discuss their advantages, disadvantages, and results.