Corelation among clinical, biochemical and tomographic criteria in order to evaluate the severity in acute pancreatitis Correlación entre criterios clínicos, bioquímicos y tomográficos para evaluar la gravedad de la pancreatitis aguda

Background: the acute pancreatitis is an inflammatory process that may involve peripancreatic tissue and distant organs. According to the Atlanta criteria, in 10 to 20% of the patients the disease is severe. Nowadays there are different clinical and biochemical severity scales such as the Ranson, APACHE-II (Acute Physiology and Chronic Health Evaluation) and hematocrit, which have discrepancies when being compared to tomographic scales such as the Balthazar. There exist few studies that correlate these parameters. Objective: to evaluate the severity of the acute pancreatitis according to the Ranson, APACHE-II and serous hematocrit criteria at the moment of admission of the patient and correlate these scales with the local pancreatic complications according to the Balthazar classification. Patients and method: retrospective, observational and analytic study. There were included patients of any gender above the age of 18, with diagnosis of acute pancreatitis of any etiology, who had performed an abdominal tomography 72 hours after the beginning of the clinical condition in order to stage the pancreatic damage. The diagnosis of acute pancreatitis was established with 2 of the 3 following criteria: a) characteristic abdominal pain; b) uprising of the amylase and/or lipase more than 3 times above the superior normal limit; and c) characteristic finds of acute pancreatitis in the computed tomography. In order to make the correlation, the Pearson or the Spearman tests were used according to the distribution of the variables. Results: there were included 28 patients (21 masculine, 75%). The most frequent etiology was due to alcohol (53.6%, bile (21.4%) and hypertriglyceridemia (17.9%). The age average was 38.1 years old. Fifty per cent of the patients had acute severe pancreatitis according to the Atlanta criteria. Of the patients with APACHE-II less than 8 points, 62.5% were classified according to the Balthazar tomographic scale as D or E degree. Ninety-two point nine per cent of the patients had less than 3 Ranson criteria of which 57.6% got D or E degree. Fifty-seven per cent of the patients with hematocrit value lower than 44% got D and E Balthazar degree, and 64.2% of the patients with hematocrit above 44% got D and E degree. The Pearson correlation (PC) for APACHE-II and Ranson p = 0.013 of 0.476 PC for APACHE-II and Balthazar p = 0.367 of 0.476 and Spearman´s correlation p = 0.460 PC for APACHE-II and hematocrit p = 1.32 of 0.476. Conclusions: there does not exist a good correlation between the seriousness scale of Ranson and APACHE-II with the tomographic Balthazar degrees, therefore it is more likely to find very ill patients with an A or B Balthazar and on the other hand patients with acute low pancreatitis with a D or E Balthazar.Antecedentes: la pancreatitis aguda es un proceso inflamatorio que puede involucrar tejido peripancreático y órganos distantes. En 10 a 20% de los pacientes la enfermedad es severa, según criterios de Atlanta. En la actualidad existen diferentes escalas clínicas y bioquímicas de severidad como la de Ranson, APACHE-II (Acute Physiology and Chronic Health Evaluation) y hematocrito, las cuales tienen discrepancias al compararlas con escalas tomográficas como la de Balthazar. Existen pocos estudios que correlacionen estos parámetros. Objetivo: evaluar el grado de severidad de la pancreatitis aguda según criterios de Ranson, APACHE-II y hematocrito sérico al ingreso y correlacionar estas escalas con las complicaciones locales pancreáticas según la clasificación de Balthazar. Pacientes y método: estudio retrospectivo, observacional y analítico. Se incluyeron pacientes mayores de 18 años de cualquier género, con diagnóstico de pancreatitis aguda de cualquier etiología, a los que se les realizó tomografía abdominal 72 horas posterior al inicio del cuadro clínico para estadificar el daño pancreático. El diagnóstico de pancreatitis aguda se estableció con 2 de 3 de los siguientes criterios: a) dolor abdominal característico; b) elevación de amilasa y/o lipasa a más de 3 veces por arriba del límite superior normal; y c) hallazgos característicos de pancreatitis aguda en la tomografía computada. Para correlación se utilizó la prueba de Pearson o la de Spearman según la distribución de las variables. Resultados: se incluyeron 28 pacientes (21 masculinos, 75%). La etiología más frecuente fue por alcohol (53,6%), biliar (21,4%) e hipertrigliceridemia (17,9%). El promedio de edad fue de 38,1 años. El 50% de los pacientes cursaron con pancreatitis aguda severa según criterios de Atlanta. De los pacientes con APACHE-II menor a 8 puntos, el 62,5% según la escala tomográfica de Balthazar fueron clasificados como grado D o E. El 92,9% de los pacientes tuvieron menos de 3 criterios de Ranson de los cuales el 57,6% obtuvieron grado D o E. El 57% de los pacientes con valor de hematocrito menor a 44% obtuvieron grado D y E de Balthazar, y 64,2% de los pacientes con hematocrito mayor a 44%, obtuvieron grado D y E. La correlación de Pearson (CP) para APACHE-II y Ranson p = 0,013 DE 0,476. CP para APACHE-II y Balthazar p = 0,367 DE 0,476 y correlación de Spearman’s p = 0,460. CP para APACHE-II y hematocrito p = 1,32 DE 0,476. Conclusiones: no existe una buena correlación entre la escala de gravedad de Ranson y APACHE-II con los grados tomográficos de Balthazar, por lo cual es probable encontrar pacientes muy graves con un Balthazar A o B y en forma contraria pacientes con pancreatitis aguda leve con Balthazar D o E

Evaluación del estado nutricional de pacientes con cirrosis hepática alcohólica atendidos en la Clínica de Hígado del Hospital General de México Nutritional assessment of alcoholic liver cirrhotic patients treated in the liver Clinic of the Mexico's General Hospital

La desnutrición en el paciente cirrótico se asocia a mayor morbi-mortalidad; sin embargo, su diagnóstico es complejo por lo que el objetivo del estudio fue evaluar el estado nutricional empleando distintos métodos. Se evaluaron pacientes adultos con cirrosis hepática de origen alcohólico que acudieron a la Clínica de Hígado del Hospital General de México. Se aplicó un recordatorio de 24 horas y antropometría, herramientas de tamizaje (Malnutrition Universal Screening Tool, Nutritional Risk Screening-2002) y de diagnóstico nutricional específica para pacientes con cirrosis hepática (Royal Free Hospital Global Assessment). Se incluyeron 62 pacientes y 51,6% fueron hombres. La desnutrición por área muscular de brazo fue de 31,3% en hombres y de 10% en mujeres, y por área grasa de brazo fue de 23,3% en mujeres y 3,1% en hombres (p Malnutrition in the cirrhotic patient is associated to a higher morbidity and mortality rate; however, the diagnosis is complex, so the study objective was to assess the nutritional status using different methods. Adult patients with alcoholic liver cirrhosis treated in the Liver Clinic of the Mexico's General Hospital were evaluated. Anthropometric measurements and a 24 hours recall were made; screening tools (Malnutrition Universal Screening Tool, Nutritional Risk Screening-2002) and a method for assessing nutritional status specifically in cirrhotic patients (Royal Free Hospital Global Assessment) were used. We included 62 patients, 51.6% of them were men. Malnutrition by arm muscle area was 31.3% in men and 10% in women, and by arm fat area was 23.3% in women and 3.1% in men (p < 0.05). With the screening tools the percentages of malnutrition risk were 43.5% and 54.8% respectively, vs. 1.6% identified as "low weight" with the Body Mass Index. With the Royal Free Hospital Global Assessment tool the percentage of malnutrition was 45.2%. Patients with malnutrition had an energy and protein intake significantly lower than the well-nourished: 19.7 kcal/kg and 0.89 g/kg vs 30 kcal/kg and 1.25 g/kg (p < 0.005). Malnutrition is a common complication in patients with liver cirrhosis. Men have higher depletion of muscle mass and women a higher loss of body fat. The Body Mass Index is not a reliable tool for assessing malnutrition. It's advisable to use tools with indicators of body composition such as the Royal Free Hospital Global Assessment

Intravenous supplementation type and volume are associated with 1-year outcome and major complications in patients with chronic intestinal failure.

BACKGROUND AND AIM No marker to categorise the severity of chronic intestinal failure (CIF) has been developed. A 1-year international survey was carried out to investigate whether the European Society for Clinical Nutrition and Metabolism clinical classification of CIF, based on the type and volume of the intravenous supplementation (IVS), could be an indicator of CIF severity. METHODS At baseline, participating home parenteral nutrition (HPN) centres enrolled all adults with ongoing CIF due to non-malignant disease; demographic data, body mass index, CIF mechanism, underlying disease, HPN duration and IVS category were recorded for each patient. The type of IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorised as 3 L/day. The severity of CIF was determined by patient outcome (still on HPN, weaned from HPN, deceased) and the occurrence of major HPN/CIF-related complications: intestinal failure-associated liver disease (IFALD), catheter-related venous thrombosis and catheter-related bloodstream infection (CRBSI). RESULTS Fifty-one HPN centres included 2194 patients. The analysis showed that both IVS type and volume were independently associated with the odds of weaning from HPN (significantly higher for PN 1 L/day), patients' death (lower for FE, p=0.079), presence of IFALD cholestasis/liver failure and occurrence of CRBSI (significantly higher for PN 2-3 and PN >3 L/day). CONCLUSIONS The type and volume of IVS required by patients with CIF could be indicators to categorise the severity of CIF in both clinical practice and research protocols