Estudio epidemiológico, observacional, prospectivo para evaluar la utilidad pronóstica de la antitrombina III y el dímero d en el desarrollo de pancreatitis aguda moderada o grave

La pancreatitis aguda és una de les malalties gastrointestinals més freqüents. La seva incidència ha augmentat en els darrers anys. Aproximadament el 20% dels pacients progressen a una forma greu associant una morbimortalitat elevada. Per minimitzar-la, cal iniciar una ressucitació adequada de forma precoç. Per tant, la identificació precoç dels pacients amb risc de desenvolupar un quadre clínic greu és crucial. S'han estudiat diverses escales de predicció de gravetat i també diversos biomarcadors, sent la proteïna C reactiva el més utilitzat actualment a la pràctica clínica habitual. L'antitrombina III i el dímer D s'han proposat com a predictors de gravetat de la pancreatitis aguda en alguns estudis, però el seu valor predictiu continua sense estar clar. L'objectiu principal d'aquest estudi és analitzar si els nivells d'antitrombina III i el dímer D a l'ingrés o durant les primeres 24 hores poden predir la progressió a pancreatitis aguda moderada o greu. En segon lloc, determinar-ne el valor predictiu sobre el desenvolupament de necrosi, necrosi infectada, insuficiència orgànica i mortalitat. Es tracta d'un estudi observacional prospectiu realitzat en pacients amb pancreatitis aguda lleu que van ingressar a dos hospitals de tercer nivell en un període de 3 anys (2015-2017). S'han inclòs 346 pacients amb pancreatitis aguda lleu. Quaranta-quatre pacients (12,7%) van evolucionar a pancreatitis aguda moderada o greu. Es va detectar necrosi en 36 pacients (10,4%); en 10 (2,9%) es va confirmar la infecció. Es va registrar disfunció orgànica en 9 (2,6%); dels quals tots van morir. Els pacients que van progressar a pancreatitis aguda moderada o greu van mostrar nivells més baixos d'antitrombina III. Els nivells de dímer D i proteïna C reactiva van augmentar. El millor marcador individual per a la predicció de pancreatitis aguda moderada o greu és la proteïna C reactiva amb una AUC 0.839. Antitrombina III i dímer D mostren un valor predictiu inferior amb una AUC 0.641 i 0.783 respectivament. Es van observar resultats semblants amb necrosi i necrosi infectada, encara que lleugerament superiors, sobretot en els pacients que van presentar necrosi infectada. En el cas de disfunció orgànica i mort, la creatinina va ser el millor marcador individual, encara que l'antitrombina III i el dímer D van mostrar també un valor predictiu alt.La pancreatitis aguda es una de las enfermedades gastrointestinales más frecuentes. Su incidencia ha aumentado en los últimos años. Aproximadamente el 20% de los pacientes progresan a una forma grave asociando una elevada morbimortalidad. Para minimizarla, es necesario iniciar una adecuada resucitación de forma precoz. Por tanto, la identificación temprana de los pacientes con riesgo de desarrollar un cuadro clínico grave es crucial. Se han estudiado varias escalas de predicción de gravedad y también varios biomarcadores, siendo la proteína C reactiva el más utilizado actualmente en la práctica clínica habitual. La antitrombina III y el dímero D se han propuesto como predictores de gravedad de la pancreatitis aguda en algunos estudios pero su valor predictivo sigue sin estar claro. El objetivo principal del presente estudio es analizar si los niveles de antitrombina III y dímero D al ingreso o durante las primeras 24 horas pueden predecir la progresión a pancreatitis aguda moderada o grave. En segundo lugar, determinar su valor predictivo sobre el desarrollo de necrosis, necrosis infectada, fallo orgánico y mortalidad. Se trata de un estudio observacional prospectivo realizado en pacientes con pancreatitis aguda leve que ingresaron en dos hospitales de tercer nivel en un periodo de 3 años (2015-2017). Se incluyeron 346 pacientes con pancreatitis aguda leve. Cuarenta y cuatro pacientes (12,7%) evolucionaron a pancreatitis aguda moderada o grave. Se detectó necrosis en 36 pacientes (10,4%); en 10 (2,9%) se confirmó la infección. Se registró fallo orgánico en 9 (2,6%); de los cuales todos fallecieron. Los pacientes que progresaron a pancreatitis aguda moderada o grave mostraron niveles más bajos de antitrombina III. Los niveles de dímero D y proteína C reactiva aumentaron. El mejor marcador individual para la predicción de pancreatitis aguda moderada o grave es la proteína C reactiva con una AUC 0.839. Antitrombina III y dímero D muestran un valor predictivo inferior con una AUC 0.641 y 0.783 respectivamente. Se observaron resultados similares con necrosis y necrosis infectada, aunque ligeramente superiores, sobre todo en los pacientes que presentaron necrosis infectada. En el caso de fallo orgánico y muerte, la creatinina fue el mejor marcador individual, aunque la antitrombina III y el dímero D mostraron también un valor predictivo alto.Acute pancreatitis is one of the most common gastrointestinal diseases. Its incidence has increased in recent years. Approximately 20% of patients progress to a severe form associated with high morbidity and mortality. To minimize it, it is necessary to initiate early adequate resuscitation. Therefore, early identification of patients at risk of developing a severe clinical presentation is crucial. Several severity prediction scales and also several biomarkers have been studied, with C-reactive protein being the most widely used currently in routine clinical practice. Antithrombin III and D-dimer have been proposed as predictors of acute pancreatitis severity in some studies, but their predictive value remains unclear. The main objective of the present study is to analyze whether the levels of antithrombin III and D-dimer at admission or during the first 24 hours can predict the progression to moderate or severe acute pancreatitis. Second, to determine its predictive value on the development of necrosis, infected necrosis, organ failure and mortality. This is a prospective observational study conducted in patients with mild acute pancreatitis admitted to two tertiary level hospitals over a 3-year period (2015-2017). Three hundred and forty-six patients with mild acute pancreatitis were included. Forty-four patients (12.7%) evolved to moderate or severe acute pancreatitis. Necrosis was detected in 36 patients (10.4%); in 10 (2.9%) the infection was confirmed. Organ failure was recorded in 9 (2.6%); of which all died. Patients who progressed to moderate or severe acute pancreatitis showed lower antithrombin III levels. D-dimer and C-reactive protein levels increased. The best single marker for the prediction of moderate or severe acute pancreatitis is C-reactive protein with an AUC 0.839. Antithrombin III and D-dimer show a lower predictive value with AUC 0.641 and 0.783 respectively. Similar results were observed with necrosis and infected necrosis, although slightly higher, especially in patients with infected necrosis. In the case of organ failure and death, creatinine was the best single marker, although antithrombin III and D-dimer also showed high predictive value.Universitat Autònoma de Barcelona. Programa de Doctorat en Cirurgia i Ciències Morfològique

The use of the modified Neff classification in the management of acute diverticulitis

Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. Objective: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. Material and methods: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. Results: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. Conclusions: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD

Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence: consequences of lack of resources

Introduction: Acute pancreatitis is often a relapsing condition, particularly when its triggering factor persists. Our goal is to determine the recurrence rate of acute biliary pancreatitis after an initial episode, and the time to relapse, as well as to identify the risk factors for recurrence. Material and method: We included all patients admitted for a first acute gallstone pancreatitis event during four years. Primary endpoints included readmission for recurrence and time to relapse. Results: We included 296 patients admitted on a total of 386 occasions. The incidence of acute biliary pancreatitis in our setting is 17.5/100,000 population/year. In all, 19.6% of pancreatitis were severe (22.6% of severe acute pancreatitis for first episodes versus 3.6% for recurring pancreatitis), with an overall mortality of 4.4%. Overall recurrence rate was 15.5%, with a median time to relapse of 82 days. In total, 14.2% of patients relapsed after an acute pancreatitis event without cholecystectomy or endoscopic retrograde cholangio-pancreatography. Severe acute pancreatitis recur in 7.2% of patients, whereas mild cases do so in 16.3%, this being the only risk factor for recurrence thus far identified. Conclusions: Patients admitted for pancreatitis should undergo cholecystectomy as soon as possible or be guaranteed priority on the waiting list. Otherwise, endoscopic retrograde cholangio-pancreatography with sphincterotomy may be an alternative to surgery for selected patients