Predictors of serious local complications in patients with severe acute pancreatitis

Objective

Serious local complications that can develop following the acute phase of severe pancreatitis include abscess formation, vascular injuries, and gastrointestinal (GI) perforations. These complications are caused by extensive necrosis of fat in the peri-pancreatic retroperitoneum that extends into the intraperitoneum/ retroperitoneum. The purpose of this study was to determine the predictors of such local complications.

Materials and methods

Forty-five consecutive patients who were admitted to our ICU for acute pancreatitis were the subjects of this study (male: 32, female: 13, age 51.4 ± 18.9 years). The following parameters were assessed: Ranson score; APACHE II scores, SOFA scores, and CRP levels on admission and day 7; and enhancement CT findings on admission (first CT) and days 7–10 (second CT). CT findings were assessed using the CT severity index of Balthazar and colleagues. P < 0.05 was considered statistically significant.

Results

Twelve patients with acute pancreatitis developed local complications. Five patients have GI perforations that accompanied abscess formations in three cases. Six patients have vascular injuries (arterial rupture: five cases, venous rupture: one case, venous occlusion: one case). The other patient developed intraperitoneum abscess and sepsis. A laparotomy was performed on two patients with colon perforations and one patient with an intraperitoneum abscess. Transarterial embolization was performed on five patients with arterial ruptures. Stomach and duodenum perforations were treated with percutaneous drainage. Three patients died during the study period: one from bleeding associated with arterial rupture (day 51) and two from colon perforations (days 17 and 162).

Ranson scores, APACHE II scores, SOFA scores, and CRP levels of patients who had complications on admission (C group) were 5.2 ± 2.1, 12.7 ± 8.3, 5.4 ± 3.8, and 13.4 ± 10.6 mg/dl, respectively, and those of patients who did not have complications on admission (non-C group) were 3.0 ± 1.7, 7.6 ± 5.6, 2.8 ± 3.0, and 6.6 ± 7.0 mg/dl, respectively. The Ranson, APACHE II, and SOFA scores of the C group were significantly higher than those of the non-C group. On day 7, APACH II scores, SOFA scores, and CRP levels in the C group were 11.1 ± 6.7, 5.8 ± 3.8, and 20.3 ± 6.3 mg/dl, respectively, and for the non-C group were 4.5 ± 4.3, 1.7 ± 2.5, and 5.7 ± 5.1 mg/dl, respectively. The C group had significantly higher scores and CRP levels than the nonC group. Severity indices of the first and second CT observations were 8.1 ± 1.8 and 8.2 ± 1.7, respectively, for the C group and 2.9 ± 1.3 and 2.6 ± 1.3, respectively, for the non-C group. Severity indices were significantly higher in the C group.

A multivariate logistic regression analysis using a stepwise method was performed to identify significantly independent factors associated with the development of complications. As strong correlations were observed among Ranson, APACHE II, SOFA scores, CRP levels, and CT severity indices, we selected the day 7 APACHE II scores, the day 7 CRP levels, and the CT severity indices on the second CT as variables. CT severity indices and CRP levels were significantly independent factors (P = 0.03 and 0.41, respectively). An OR for developing complications was 3.6 when a CRP level increased by 5 mg/dl (95% CI: 1.1–10.7). Similarly, the OR was 5.0 when a CT index increased by 2 points (95% CI: 1.2–21.4).

Conclusion

Persistent inflammatory reactions and high severity indices on the second CT are considered significant predictors of serious local complications associated with acute pancreatitis.