Early assessment of severity in acute pancreatitis.

Early assessment of severity in acute pancreatitisIn no other acute abdominal condition is the outcome so unpredictable at the outset.Of any four patients with acute pancreatitis, three will rapidly improve with simple supportive therapy, while the fourth develops one or more serious complications of the disease and stands about a one-in-three chance of dying.`Abetter understanding of the pathophysiology of pancreatitis, notably the fluid and oxygen requirements, has led to an overall mortality rate of around 10% in most prospective series.1 3 5 A recent study has shown, however, that a third of fatal cases are first diagnosed at necropsy.When these are included, the overall mortality rate is 20%.6Separation of patients with good and bad prognoses at the time of admission to hospital is valuable for at least three reasons.First, those with severe pancreatitis need much more vigorous resuscitation and monitoring, including admission to an intensive therapy area, urethral catheterisation and a central venous line.Acute pancreatitis is quite a common emergency and the routine adoption of these measures would be costly.Second, aggresive treatments such as peritoneal lavage, endoscopic papillotomy or urgent pancreatectomy might be justified in patients with a poor outlook, but scarcely so in the majority whose mild attacks quickly abort.Third, general acceptance of the criteria of severity would facilitate international comparisons of prospective studies.In the present issue a group of surgeons and statisticians report their success in predicting the severity of an attack of acute pancreatitis by means of laboratory tests performed within 48 hours of the-patients' arrival at the Glasgow Royal Infirmary.7In evaluating their work we need to define severe pancreatitis, to compare the many methods recommended for its detection and to determine whether the results repay the effort expended.As early operation is one option in treating acute gall stone pancreatitis, we must also consider the identification of this particular group of patients. DefinitionsAs pancreatic tissue is seldom available before death, the diagnosis of acute pancreatitis rests on appropriate clinical features with hyperamylasaemia in at least 80% of cases and on laparotomy findings in the remainder.1 3 8 There are several methods of measuring serum amylase, each with its own units; non-pancreatic isoenzymes can be excluded by electrophoresis.9The diagnostic threshold for serum amylase is controversial.It is generally set at a higher level in Britain (1000-2000 IU/1), where gall stones predominate,' 5 10 than in the United States 1331