|Year : 2020 | Volume
| Issue : 5 | Page : 416-421
Clinical and severity profile of acute pancreatitis in a hospital for low socioeconomic strata
Tanweer Karim, Atul Jain, Vinod Kumar, Ram B Kumar, Lalit Kumar, Moolchandra Patel
Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi, India
|Date of Submission||14-Jul-2020|
|Date of Acceptance||15-Jul-2020|
|Date of Web Publication||9-Nov-2020|
Department of Surgery, ESI PGIMSR, Basaidarapur, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: There is an upsurge in the incidence of acute pancreatitis over the last few decades; although the case fatality rate has remained unchanged. This may either be due to increased incidence of gallstone disease or improvement in diagnostic modalities. It is a potentially life threatening disease with varying severity of presentation. Methods: This observational analytical study was conducted in the Department of General Surgery in our hospital for a period of one year. All patients of acute pancreatitis were included in the study as per inclusion & exclusion criteria. Observations and Results: Total 62 Patients were included in the study. Gall stones disease is the most common cause of acute pancreatitis. The mean age of the patients in the study was 39 years. 28 females and 34 male patients were present. 22 patients of the patients had severe disease as per Atlanta classification. Four out of these 22 severe pancreatitis patients expired. All patients in the severe pancreatitis group had mild to life threatening complications and pleural effusion was the most common followed by necrosis. There was notable difference in terms of hospital stay between mild group and severe group of AP. Conclusion: The clinician should be aware that acute pancreatitis can occur in any age group and gender due to different etiology. The severity of AP does not depend on etiology, age or gender and it is associated with significant morbidity and mortality. SAP can be diagnosed on clinicoradiological basis and appropriate management can be done in those patients.
Keywords: Acute pancreatitis, Atlanta classification, CT severity index, severe pancreatitis
|How to cite this article:|
Karim T, Jain A, Kumar V, Kumar RB, Kumar L, Patel M. Clinical and severity profile of acute pancreatitis in a hospital for low socioeconomic strata. Indian J Endocr Metab 2020;24:416-21
|How to cite this URL:|
Karim T, Jain A, Kumar V, Kumar RB, Kumar L, Patel M. Clinical and severity profile of acute pancreatitis in a hospital for low socioeconomic strata. Indian J Endocr Metab [serial online] 2020 [cited 2020 Nov 26];24:416-21. Available from: https://www.ijem.in/text.asp?2020/24/5/416/300336
| Introduction|| |
Acute pancreatitis (AP) is a potentially life threatening disease with varying severity of presentation. Nearly 60-80% of all cases of AP in developed countries are attributable to either gallstone disease or alcohol abuse.
There is an upsurge in the incidence of AP over the last few decades, although the case fatality rate has remained unchanged. This may either be due to increased incidence of gallstone disease or improvement in diagnostic modalities. The incidence of alcoholic pancreatitis is higher in male and even risk of developing acute pancreatitis with gallstone disease is higher in male. However, increased number of young females develop this disorder due to higher incidence of gallstones in this subset of population.
Acute pancreatitis is mild and resolves itself without serious complications in 80% of patients. Morbidity and mortality occur in up to 20% of patients despite the aggressive intervention.
This is usually due to systemic inflammatory response syndrome and organ failure in the first two-week period, while after two weeks it is usually due to sepsis and its complications.
In a systematic review of studies of acute pancreatitis, overall mortality was approximately 5%. Mortality rates in patients with interstitial and necrotizing pancreatitis were 3%, and 17%, respectively.
Abdominal pain is seen in patients with acute pancreatitis. Pancreas being a solid retro-peritoneal organ, the pain is epigastric and of deep boring nature often radiating to back. Physical examination usually reveals a distended abdomen with epigastric tenderness and sluggish bowel sounds. Occasionally, patients may have a rigid abdomen mimicking surgical condition. Patients may present with abdominal pain and shock with very little abdominal findings. Ecchymosis in the flank (Grey Turner's sign) or near umbilicus (Cullen's sign) are also seen in few patients. These patients have a high mortality.
This study was done with objective to observe the clinical and severity profile of patients diagnosed with AP and related morbidity and mortality in our institution.
| Methods|| |
This observational analytical study was conducted in the Department of General Surgery in our hospital after due permission from the Institute Ethical Committee for a period of one year.
All patients of acute pancreatitis were included in the study with following inclusion and exclusion criteria:
- Age group >18 years and <70 years (Both male and female)
- All patients attending emergency/OPD with diagnosis or diagnosed as case of acute pancreatitis
- Patients willing to participate in the study.
- Chronic pancreatitis
- Pancreatic Malignancy
- Patients not willing to participate in the study.
The diagnosis of acute pancreatitis was made as per guidelines by American Gastroenterological Association (AGA) and according to revised Atlanta classification (2012): two of the following three features.
- Abdominal pain: clinically suggestive of acute pancreatitis
- Serum lipase (or amylase) at least three times the normal upper limit
- Radiological findings (USG/CT/MRI) suggestive of acute pancreatitis.
Written & informed consent from patients was taken for the study. A detailed history including present medical history and previous surgical morbidity/intervention was taken. Detailed clinical examination was carried out including general physical examination, systemic examination and local examination.
| Observations and Results|| |
The mean age of the patients in the study was 39.21 ± 12.43 years. 29.03% of the patients were in the age group 31-40 years, 24.19% of the patients were in the age group 41-50 years and 19.35% of the patients were in the age group 21-30 years; with few patients ≤ 20 years and >50 years [Table 1].
In our study, 45.16%(28) were females and 54.84%(34) were males [Pie Chart 1].
Gall stone was present in majority (67.74%) of patients followed by alcohol (17.74%) and idiopathic (14.52%) [Pie Chart 2].
The most common complaint of patients at the time of presentation to hospital was pain abdomen (100%) followed by, fever (20%) and abdominal distension (29%). Nausea/Vomiting was seen in 10 (16%) only [Pie Chart 3].
According to revised Atlanta classification, majorities (64.52%) of patients were categorized as mild acute pancreatitis and 35.48% of patients were categorized as severe acute pancreatitis [Table 2].
|Table 2: Severity according to revised Atlanta classification and Modified CT severity index|
Click here to view
According to modified CT severity index, majority (53.23%) of patients were categorized as moderate acute pancreatitis followed by 30.65% of patients as severe acute pancreatitis and 16.13% of patients as mild acute pancreatitis. Mean value of modified CT severity index of study subjects was 5.13 ± 2.53 [Table 2].
In this study, incidence of complications was 38.71%. Majority of patients had pleural effusion followed by necrosis. 11.29% of patients had ascitis, and very few patients had MODS and pseudocyst [Table 3]. 4 out of 62 patients died due to MODS [Pie Chart 4].
Mean value of ALP, serum amylase, and lipase of study subjects was 175.77 ± 74.27 IU/L, 735.16 ± 452.78 U/L, and 1200.23 ± 1015.25 U/L respectively.
Mean value of blood urea and hemoglobin was 36.44 ± 13.81 mg/dl and 10.95 ± 1.28 g/dl with median (interquartile range) of 36 (27-43) mg/dl and 10.9 (10-12) g/dl respectively.
Mean value of platelet count was 2.72 ± 1.1 lac/mm3 (per microliter) with interquartile range within normal limits (1.9-3.5 lac/mm3 (per microliter). Mean value of TLC was 9062.9 ± 3011.58 (per microliter).
Mean value of serum bilirubin and creatinine was 1.17 ± 0.53 mg/dl and 1.27 ± 0.63 mg/dl respectively. Values of serum sodium and potassium were 138.6 ± 4.11 meq/L and 4.14 ± 0.54 meq/L, respectively.
Mean value of SGOT and SGPT was 62.53 ± 27.79 IU/L and 65.21 ± 27.97 IU/L respectively [Table 4].
Mean value of pulse rate of study subjects was 87 ± 11.48 bpm. Systolic and diastolic blood pressure of study subjects was recorded as 120.44 ± 14.1 mmHg and 76.45 ± 12.6 mmHg [Table 5].
Mean duration of hospital stay was 9.95 ± 3.64 days with median (interquartile range) of 9 (7-13) days [Figure 1].
No significant association exists between modified CT severity index and etiology. (P > 0.05) Distribution of modified CT severity index was comparable between different etiologies with no significant difference between them. Proportion of patients categorized as mild acute pancreatitis in alcohol, gall stone and idiopathic was 18.18%, 14.29% and 22.22% respectively. Though in patients with gall stone and idiopathic etiology, proportion of patients categorized as moderate acute pancreatitis was higher as compared to alcohol yet the difference was not statistically significant [Bar Graph 1].
No significant association exists between severity according to revised Atlanta classification and etiology. (P > 0.05) Distribution of severity according to revised Atlanta classification was comparable between different etiologies with no significant difference between them. Proportion of patients categorized as mild acute pancreatitis in alcohol, gall stone and idiopathic was 45.45%, 69.05% and 66.67% respectively. Though in patients with gall stone and idiopathic etiology, proportion of patients categorized as mild acute pancreatitis was higher as compared to alcohol yet the difference was not statistically significant [Bar Graph 2].
| Discussion|| |
In this study, majority (29.03%) of the patients were in the age group 31-40 years, 24.19% of the patients were in the age group 41-50 years and 19.35% of the patients were in the age group 21-30 years. Patients were between 18-70 years of age with mean age of 39 years. In similar studies, the mean age of 42.9 years (age range 18-80 years) was reported in a study by Raghu M G et al. and the mean age of 30 years was reported by Baig et al. This indicates that acute pancreatitis can occur in any age group but 30-50 age group is more affected.
In our study, 45.16% subjects were females and 54.84% were males (M:F = 1.2:1), which is comparable to studies by Negi et al. (M:F = 2.6:1) and A C de Beaux (M:F = 1.6:1). Increased incidence of pancreatitis in male patients observed in earlier studies, may be attributed to higher prevalence of alcoholism.
Gall stone was the most common etiology (67.74% cases) observed in our study, followed by alcohol (17.74%) and idiopathic (14.52%). Since predominance of gall stones is more in women, especially in India, this may explain the higher prevalence of acute pancreatitis in females in our study. Marshall J B in a study found that biliary stone and alcohol account for 60-80% cases of AP, while Steinberg et al. mentioned that biliary disease is the most common cause of AP in the United states, Asia and most of Western Europe.
The average hospital stay of patients was 9 days (5-13) in mild pancreatitis and 13.5 days (9-18) in severe pancreatitis. However, in a study by Gurleyik et al. mean hospital stay was 10.3 days (range 6-19 days) in mild cases and a mean hospital stay was 21.4 days (range 12-42 days) in severe cases. Banday et al. reported 1.5, 6.9 and 14.2 days of hospital stay in mild, moderate and severe AP, respectively.
The duration of hospital stay was significantly higher in patients categorized as severe acute pancreatitis as compared to patients categorized as mild and moderate acute pancreatitis probably due to increased tissue damage by inflammatory mediators. However, duration of hospital stay was not found to be significantly associated with etiology.
Value of lipase and duration of hospital stay was significantly higher in patients categorized as severe acute pancreatitis by revised Atlanta classification as compared to patients categorized as mild acute pancreatitis.
Gungor et al. stated that there must be three times increase in serum amylase level for making a diagnosis of AP. In our study, values of amylase in patients categorized as severe acute pancreatitis was 913.73 ± 601.19 U/L and in mild cases it was 636.95 ± 313.3 U/L. Though the value of amylase was higher in severe as compared to mild pancreatitis, the difference was not found to be statistically significant.
A study by Gomez et al. showed that serum amylase levels are not required and lipase level alone is sufficient to diagnose AP. No significant association was seen between amylase and severity of disease according to revised Atlanta classification and modified CT severity index. We found that values of amylase and lipase were higher in idiopathic etiology as compared to alcohol and gall stone but the difference was not statistically significant (P > 0.05).
The incidence of complications in present study was 38.71%. Majority of patients had pleural effusion (29.03%) followed by necrosis (22.58%), ascites (11.29%), MODS (6.45%) and pseudocyst (4.84%). Chauhan Y et al. also reported Pleural effusion in 22% patients and 18% was reported by Maharaul. Viedma et al., Lankisch et al. and Toh et al. also noted that respiratory failure was the most common type of organ failure in SAP.
Abdominal pain (epigastric pain with radiation to the back) was the most common presenting complaint in all patients (100%) and fever was seen in 20% patients, which co-relates with the studies by Negi et al. and Chauhan Y et al.
Four out of 62 (6.45%) patients died due to severe acute pancreatitis. In our study, major cause of death was MODS. Mann et al. and Banerjee et al. separately noted that in acute pancreatitis the average mortality rate approaches 2-10% while Steinberg et al. noted a mortality of 2-9% in his study.
| Conclusion|| |
The clinician should be aware that acute pancreatitis can occur in any age group and gender due to different etiology. The diagnosis of AP is made on clinical and biochemical basis but the severity is not indicated by routinely used diagnostic biochemical parameters like amylase and lipase. It is difficult to predict the course of the disease in individual patients. Advanced age and associated comorbidities are known to be related to poor or delayed outcome. Early diagnosis and treatment of cases are expected to cut short the progression of disease. However, there are cases which progressed to severe acute pancreatitis inspite of early presentation and management. Therefore, severity of AP does not depend on etiology, age or gender and socioeconomic status. Most cases of SAP can be diagnosed on clinical and radiological findings and responds to timely appropriate management. Studies to assess the role of biochemical markers for early diagnosis of SAP are there but consensus is yet to be reached.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Phillip V, Steiner JM, Algül H. Early phase of acute pancreatitis: Assessment and management. World J Gastrointest Pathophysiol 2014;5:158-68.
Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Does etiology of acute pancreatitis matter? A review of 391 consecutive episodes. JOP 2015;16:171-5.
Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population. 1963-98: Database study of incidence and mortality. BMJ 2004;328:1466-9.
Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas 2006;33:323-30.
Eland IA, Sturkenboom MJ, Wilson JH, Stricker BH. Incidence and mortality of acute pancreatitis between 1985 and 1995. Scand J Gastroenterol 2000;35:1110-6.
Baillie J. AGA Institute medical position statement on acute pancreatitis. Gastroenterology. 2007;132:2019-21.
Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA. Does mortality occur early or late in acute pancreatitis? Int J Pancreatol 2000;28:91-5.
Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101:2379-400.
Raghu MG, Wig JD, Kochhar R, Gupta D, Gupta R, Yadav TD, et al
. Lung complications in acute pancreatitis. JOP 2007;8:177-85.
Baig SJ, Rahed A, Sen S. A prospective study of the aetiology, severity and outcome of acute pancreatitis in Eastern India. Trop Gastroenterol 2008;29:20-2.
De Beaux AC, Palmer KR, Carter DC. Factors influencing morbidity and mortality in acute pancreatitis; an analysis of 279 cases. Gut 1995;37:121-6.
Negi N, Mokt J, Sharma B, Sharma B, Jhobta A, Bodh V, et al
. Clinical profile and outcome of acute pancreatitis: A hospital-based prospective observational study in Subhimalayan State. J Assoc Physicians India 2018;66:22-4.
Marshall JB. Acute pancreatitis: A review with an emphasis on new developments. Arch Intern Med 1993;153:1185-98.
Steinberg W, Tenner S. Acute pancreatitis. N
Engl J Med 1994;330:1198-210.
Gurleyik G, Emir S, Kiliçoglu G, Arman A, Saglam A. Computed tomography severity index, APACHE II score, and serum CRP concentration for predicting the severity of acute pancreatitis. JOP 2005;6:562-7.
Banday IA, Gattoo I, Khan AM, Javeed J, Gupta G, Latief M. Modified computed tomography severity index for evaluation of acute pancreatitis and its correlation with clinical outcome: A tertiary care hospital based observational study. J Clin Diagn Res 2015;9:TC01-5.
Gungor B, Caglayan K, Polat C, Seren D, Erzurumlu K, Malazgirt Z. The predictivity of serum biochemical markers in acute biliary pancreatitis. ISRN Gastroenterol 2011;2011:279607.
Gomez D, Addison A, De Rosa A, Brooks A, Cameron IC. Retrospective study of patients with acute pancreatitis: Is serum amylase still required? BMJ Open 2012;2:e001471.
Chauhan Y, Jindal N, Verma RK, Tyagi PK, Rana M, Singh S. A clinical profile and outcome of patients with acute pancreatitis: A prospective study in North India. Arch Int Surg 2018;8:132-8. [Full text]
Maharaul H, Dhorajia D. A single institute study of clinical profile of acute pancreatitis. Indian J Appl Res 2015;5:700-2.
Viedma JA, Perez-Mateo M, Agullo J, Domínguez JE, Carballo F. Inflammatory response in the early prediction of severity in human acute pancreatitis. Gut 1994;35:822-7.
Lankisch PG, Pflichthofer D, Lehnick D. Acute pancreatitis: Which patient is most at risk? Pancreas 1999;19:321-4.
Toh SK, Phillips S, Johnson CD. A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England. Gut 2000;46:239-43.
Mann DV, Hershman MJ, Hittinger R, Glazer G. Multicentre audit of death from acute pancreatitis. Br J Surg 1994;81:890-3.
Banerjee AK, Kaul A, Bache E, Parberry AC, Doran J, Nicholson ML. An audit of fatal acute pancreatitis. Postgrad Med J 1995;71:472-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]