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ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 132-138

A clinical profile and outcome of patients with acute pancreatitis: A prospective study in North India


Department of General Surgery, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Neha Jindal
Department of General Surgery, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun - 248 001, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_3_19

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  Abstract 


Background: Acute Pancreatitis (AP) is an inflammatory process. The average mortality rate in severe AP approaches 2%–10%. Gall stones and alcohol abuse account for 70% of cases of acute pancreatitis. Almost all patients have acute upper abdominal pain. Systemic complications and multi organ system failure may develop.
Patients and Methods: A prospective study conducted from November 2016 to December 2017 in Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, India, in patients who were diagnosed to have acute pancreatitis. A total of 54 patients were enrolled in the study out of which four patients had left against medical advice. The data collected were evaluated to see the outcome.
Results: Majority of patients 22 (44.0%) were in age group ranging from 41 to 60 years. Males were dominant (58%). The most common etiology was alcoholism followed by gall stone. The majority of patients were found with abdominal pain (100.0%). The majority of the patients were having moderate Balthazar CT Severity Index (CTSI) (54.0%). In all, 43 patients were having pancreatic complications and pancreatic necrosis was the commonest; 31 developed extra-pancreatic complications, among which pleural effusion was the commonest. Some patients were having multiple complications. The duration of hospital stay was highest in severe group of Balthazar CTSI. Rise in total leucocyte count, serum amylase level and low calcium levels were significantly associated with increase in pancreatic/extra-pancreatic complications. There was only 1 (2%) patient who died and remaining 49 (98%) patients were discharged.
Conclusion: Most common etiology of acute pancreatitis was alcohol consumption (50%) followed by gall stones (32%). Increases in total leucocyte count, serum amylase level and low level of serum calcium were significantly associated with increase in pancreatic/extra-pancreatic complications leading to higher morbidity and hospital stay. Patients with higher Balthazar CTSI were having higher morbidity.

Keywords: Acute pancreatitis, Balthazar CT severity index, pancreatic abscess, pancreatic necrosis, pancreatic pseudocyst


How to cite this article:
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

How to cite this URL:
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 [serial online] 2018 [cited 2019 Oct 19];8:132-8. Available from: http://www.archintsurg.org/text.asp?2018/8/3/132/268126




  Introduction Top


Acute pancreatitis (AP) is an inflammatory process due to auto-digestion of the gland by pancreatic digestive enzymes, leading to impairment of function or any morphologic changes.[1] It can re-occur intermittently, contributing to ongoing insult, referred to as 'Chronic Pancreatitis' (CP).[2] Severe AP (SAP) develops in about 25% of patients with AP. The average mortality rate in SAP approaches 2%–10%.[3] Most cases of AP are mild.[4]

The incidence of AP is much higher in USA.[5] Hospitalization rates due to AP are found to increase progressively with age.[6] For people aged 35-75 years, the rates double for males and quadruple for females.[7] AP runs a benign course in Asian countries and the etiology is different from that of the western population. Gall stones and alcohol abuse account for 70% of cases of AP.

The clinical features and the severity of AP are related to extra pancreatic organ failure secondary to the patient's systemic inflammatory response syndrome (SIRS) elicited by acinar cell injury.[8] The spectrum of AP ranges from interstitial pancreatitis, which is a mild and self-limited disorder to necrotizing pancreatitis.

Almost all patients with AP have acute upper abdominal pain at onset [9] typically accompanied in approximately 90% of patients by nausea and vomiting.

According to the severity, AP is divided into mild AP (absence of organ failure and local or systemic complications), moderately severe AP (no organ failure or transient organ failure less than 48 hours with or without local complications) and severe AP (persistent organ failure more than 48 hours that may involve one or multiple organs).[10]

Several studies have been done for comparison of various scores have found out that no single scoring index could accurately predict the outcome but they were useful in initial triaging of patients.[11],[12]

Systemic complications, clotting abnormalities, prolonged ileus, acute respiratory distress syndrome, renal failure, and multi organ system failure may develop in patients with severe AP.[13]

The early diagnosis of pancreatitis and its complication is still difficult and natural history as well as the prognosis of the disease remains yet to be defined. The clinical profile, complications and response to therapy may be different in different parts of the world and it is therefore important that experiences from different parts of the country be recorded.[14]

In AP, C-reactive protein is a useful marker only 48 hours after the onset of acute episode [15] and overall usefulness of the remaining markers is restricted by their limited availability or elevated cost. Thus, so far, no early, accessible and economical predictive marker for severe AP has yet been described.[16]

The main objective of this study was undertaken to observe the clinical presentations and outcome of AP.


  Patients and Methods Top


This is a hospital-based prospective type of observational study which was conducted from November 2016 to December 2017 in Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, India, in patients who were diagnosed to have AP. The study was conducted after approval from the Institutional Ethics committee. A total of 54 patients were enrolled in the study after obtaining written and informed consent out of which 4 patients had left against medical advice. The data collected were evaluated to see the outcome.

All patients with a diagnosis of AP were included in this study with following selection criteria:

Diagnostic Criteria: Presence of at least two of the following:

  1. Acute abdominal pain and tenderness suggestive of pancreatitis
  2. Serum amylase/lipase ≥3 times the normal
  3. Imaging findings (USG and/or CT) suggestive of AP.


Patients with chronic pancreatitis and pancreatic malignancy were excluded. Patients with moderate and severe pancreatitis were managed in ICU. Patients with mild pancreatitis were managed in ward.


  Results Top


Age

In our study, the youngest patient was 19 years and the oldest was 75 years. Majority of patients 22 (44.0%) were in age group ranging from 41 to 60 years followed by the age group ranging from 21 to 40 years [Table 1].
Table 1: Age wise distribution of patients with AP

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Gender

Males were dominant (58%) in our study than females (42%) [Table 2].
Table 2: Gender wise distribution of patients with AP

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Etiology

The most common etiology was alcoholism with 25 (50%) males followed by gall stone with 13 (61.9%) females and 3 (10.3%) males [Table 3].
Table 3: Etiological factors of patients with AP

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Chief complaints

The majority of patients were found with abdominal pain (100.0%) followed by nausea and vomiting (42%). Fever was seen in 38% [Table 4].
Table 4: Clinical presentation of patients with AP

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Laboratory values

Following are the laboratory parameters [Table 5].
Table 5: Laboratory values of patients with AP

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Balthazar CT severity index

The majority of the patients were having moderate Balthazar CT severity index (CTSI) (54.0%) [Table 6].
Table 6: Balthazar CT severity index in patients with AP

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Period of ICU care distribution

ICU care was required in 26 (52.0%) patients. ICU stay of more than 7 days was seen in 17 (65.3%) patients.

Complications

In all, 43 patients were having pancreatic complications [Table 7]. Some patients were having multiple pancreatic complications. Pancreatic necrosis [Figure 1] was the commonest pancreatic complication followed by acute fluid collection [Figure 2], pancreatic pseudocyst [Figure 3] and pancreatic abscess [Figure 4].
Table 7: Pancreatic complications in patients with AP

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Figure 1: CT scan imaging of pancreatitis with pancreatic necrosis

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Figure 2: CT scan imaging of pancreatitis with necrosis and acute fluid collection

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Figure 3: CT scan imaging of pancreatitis with pseudocyst pancreas

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Figure 4: CT scan imaging of pancreatitis with pancreatic abscess

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Out of 50 patients with AP, 31 developed extra-pancreatic complications. [Table 8] Some patients were having multiple complications.
Table 8: Extra-pancreatic complications in patients with AP

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Duration of hospital stay

The duration of hospital stay was highest in severe group of Balthazar CTSI followed by moderate and then mild [Table 9].
Table 9: Duration of hospital stay

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Complication rate in relation to raised laboratory values

Rise in total leucocyte count and serum amylase level were significantly associated with increase in pancreatic/extra-pancreatic complications. Also, low calcium levels were significantly associated with increase in pancreatic/extra-pancreatic complications. However, rise in C-reactive protein, creatinine and serum lipase levels were not significantly associated with increase in pancreatic/extra-pancreatic complications [Table 10].
Table 10: Complication rate in relation to raised laboratory values

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Outcomes distribution

There was only 1 (2%) patient who died and remaining 49 (98%) patients were discharged.

Follow-up findings

In our study, 1-year follow-up was done in all patients. There were eight patients reported with recurrence of AP in follow-up. Further observations were elaborated in following tables.

Etiology of patients with recurrent AP

The majority of patients showed recurrence due to continued alcohol consumption (50.0%) [Table 11].
Table 11: Etiology of patients with recurrent AP

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Balthazar CTSI in patients with recurrent AP

The majority of patients with recurrent AP were in moderate group of Balthazar CTSI [Table 12].
Table 12: Balthazar CTSI in patients with recurrent AP

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  Discussion Top


Our study has been conducted in 50 patients and is hospital-based prospective study. In our study, majority of the patients were in the age group of 41-60 years (44%) followed by patients 21-40 years of age (40%) and 7 (14%) patients were above 60 years of age. This can be explained by more alcohol consumption in middle aged males as compared to other age groups. This is comparable to the studies done by Negi et al.[16] where 47.15% were in the age group of 41-60 years and 43.91% were in the age group of 18-40 years. However, the peak incidence of 30 years was reported in a study done by Baig et al.[17] indicating younger age group being affected.

In our study, males outnumbered females and the male to female ratio was 1.38:1. This is comparable with studies of Negi et al.[16] where male to female ratio was 2.6:1.

In our study, alcohol was the commonest cause of pancreatitis (50%) followed by gall stone pancreatitis (32%). Alcohol was the commonest cause of pancreatitis (59.34%) followed by gall stone pancreatitis (32.52%) in a study done by Negi et al.[16] However, the study done by Buchler MW, et al.[18] shows gall stone as the main etiological factor. In Asia Gall stone associated pancreatitis predominates while in United States, alcohol abuse is the main cause. In female, gall stone pancreatitis is more common and in males, alcohol induced pancreatitis is more common.

In our study, abdominal pain was the most common presenting complaint in all patients (100%). This co-relates with the studies by Negi et al.[16] In our study, Vomiting was seen in 42% and fever was seen in 38%. This is comparable to the study done by Negi et al.[16] where vomiting was seen in 42.27% and fever was seen in 22.4%.

In our study, total count of WBC >11,000/cumm was seen in 33 (66%) of the patients. Similar study was done by KU Ahmed et al.[19] where total count of WBC >15,000/cumm were in 15 (30%) of the patients. In our study, patients with increased total leucocyte count have significantly higher incidence of pancreatic and extra-pancreatic complications (P-value = 0.005).

In our study, 9 (18%) of the patients of AP have low serum calcium. In the study done by KU Ahmed et al.[19], hypocalcemia was seen in 4 (8%) of the patients with AP. In our study, hypocalcemia was associated with higher morbidity and hospital stay as patients with low serum calcium had significantly higher incidence of pancreatic and extra-pancreatic complications (P-value:0.00003).

High levels of CRP were seen in 23 (46%) of the patients in our study which includes patients from severe and moderate groups of Balthazar CTSI of AP but it was not significantly correlated with pancreatic and extra-pancreatic complications (P-value = 0.29). This is in contrast to the study done by Joshi et al.[20] where higher CRP levels are significantly associated with complications.

In our study, elevated serum creatinine concentration (>2 mg/dl) was seen in 12 (24%) of the patients but statistically it was not associated with increase in incidence of pancreatic and extra-pancreatic complications. This is comparable to study done by Lankisch et al.[21] which indicates that if serum creatinine is normal, necrotizing pancreatitis is unlikely and CT need not be performed unless patient's condition deteriorates.[21]

In present study, serum amylase level was raised in 45 (90%) of the patients while serum lipase level was raised in 49 (98%) of the patients. Gungor et al.[22] stated that there must be a three times increase in serum amylase level for diagnosis of AP. This is similar to our study. However, five patients had serum amylase levels within normal limits where diagnosis was made by CT scan. A study by Gomez et al.[23] showed that serum amylase levels are not required and lipase level alone is sufficient to diagnose AP.

In our study, the most common pancreatic complication was pancreatic necrosis seen in 23 (46%) of the patients. This is similar to study done by Buchler et al.[3] which showed 42% of the patients with pancreatic necrosis. However, study done by Maharaul et al.[24] showed pancreatic necrosis in only 2% of the patients.

Acute fluid collection was seen as second common pancreatic complication in our study and was evident in 13 (26%) of the patients. However, study done by Buchler [18] and Maharaul [24] showed this complication in only 5% and 6% of the patients, respectively.

Pancreatic pseudocyst was seen in 6 (12%) of the patients in our study while it was observed in 4% and 2% patients in studies done by Maharaul [24] and Buchler [18], respectively.

Pleural effusion was seen in 11 (22%) of the patients in our study which is similar to study done by Maharaul [24] where it was seen in 18% of the patients. However, pleural effusion was observed in 5% of the patients in a study by Buchler.[3]

In our study, mean duration of hospital stay according to Balthazar CTSI in mild, moderate and severe groups were 6.4, 13.1 and 19.7 days, respectively, which shows that increase in severity in Balthazar CTSI is associated with increased duration of hospital stay and increased morbidity. This is similar to the study conducted by Banday et al.[25] showing 1.5, 6.9 and 14.2 days of hospital stay in mild, moderate and severe AP, respectively.

In our study, 49 (98%) of the patients have recovered and discharged, while 1 (2%) of the patients died. However, the study conducted by Negi et al.[16] showed recovery of 94.3% of the patients with 5.7% of the mortality. Early identification and aggressive treatment of associated organ dysfunction can be one of the factors which had major impact on outcome, early assessment of prognosis and severity played a significant role. ICU care was given to 26 (52.0%) patients in our study based upon the prognosis and severity. Apart from supportive therapy, prophylactic antibiotics were instituted in severe AP patients. We also initiated early enteral nutrition after initial resuscitation. Also, endoscopic retrograde cholangiopancreatography (ERCP) was performed within 48-72 hours of onset of symptoms in patients with obstructive jaundice. However, no intervention for pancreatic necrosis was done in any of the patients until 3-4 weeks.

If we compare these criteria to other studies, various results have been shown. However, we have not discussed the management of the patients in the present study. One patient with AP, who died in our study, was in severe group of Balthazar CTSI with pancreatic abscess as a pancreatic complication with hospital stay of 32 days.

In our study, recurrent AP was observed in 8 (16%) of the patients with continued alcohol consumption has the commonest cause (50%) followed by smoking (25%) and biliary complication (25%). The study done by Kedia et al.[26] showed biliary obstruction and alcohol consumption as the major etiology in recurrent AP followed by idiopathic in 30% cases.[24]


  Conclusion Top


Most common etiology of AP was alcohol consumption (50%) followed by gall stones (32%). Incidence of AP was more in 40-60 years (46%) of the age group with male to female ratio of 1.38:1. Pancreatic necrosis, pleural effusion and hypocalcemia were commonly observed complications in AP.

Increases in total leucocyte count, serum amylase level and low level of serum calcium were significantly associated with increase in pancreatic/extra-pancreatic complications leading to higher morbidity and hospital stay. Patients with higher Balthazar CTSI were having higher morbidity.

Most common cause of recurrent pancreatitis was continuation of alcohol consumption.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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