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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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Predictors of Severity of Acute Pancreatitis

Kyewhon Kim , Sung Bum Kim

Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

Correspondence to: Sung Bum Kim
ORCID https://orcid.org/0000-0001-8447-2176
E-mail sbkim@yu.ac.kr

See “Comparison of Interleukin-6, C-Reactive Protein, Procalcitonin, and the Computed Tomography Severity Index for Early Prediction of Severity of Acute Pancreatitis” by In Rae Cho, et al. on page 629, Vol. 17, No. 4, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2023;17(4):493-494. https://doi.org/10.5009/gnl230235

Published online July 15, 2023, Published date July 15, 2023

Copyright © Gut and Liver.

Acute pancreatitis (AP) is a non-bacterial inflammation of the pancreas. Based on the development of local complications and/or organ failures, its severity is classified into mild, moderately severe, and severe according to the revised Atlanta classification.1 Moderately severe and severe AP comprise approximately 15% to 25% of all cases. The mortality rate differs according to severity; mild AP has a very low mortality, whereas severe AP has a mortality as high as 36% to 50%.1

Early recognition of severity of AP is crucial for management of AP and predictors of severity of AP reported in previous studies include clinical features, laboratory tests, radiologic findings, and various scoring systems. Hematocrit, blood urea nitrogen, C-reactive protein (CRP), and serum creatinine are routinely performed laboratory tests that can predict the severity of AP. Other markers include interleukin (IL)-1, 6, and 8, procalcitonin, trypsinogen activation peptide, polymorphonuclear elastase, pancreatic-associated protein, procarboxypeptidase-B, carboxypepsidase-B activation peptide, trypsinogen-2, phospholipase A-2, substance P, antithrombin III, and platelet activating factor. The scoring systems include the Ranson score, Glasgow score, Acute Physiology and Chronic Health Evaluation II score, bedside index of severity in AP, and harmless AP score. Balthazar score and computed tomography severity index (CTSI) score using radiologic images were also used to predict severity of AP. The targets of these predictors varied among studies, including only severe AP, both moderately severe and severe AP, organ failure, and local or systemic complications.2

Cho et al.3 conducted a retrospective study to investigate the role of inflammatory markers, including IL-6, procalcitonin, and CRP, and various scoring systems including CTSI, in differentiating mild from moderately severe and severe AP. Total 103 patients including 42 (40.8%) with mild AP were included. The area under the receiver operating characteristic curve for IL-6 at admission and CRP measured 24 hours after admission, and CTSI, were 0.775, 0.787, and 0.851, respectively; these markers were identified as useful predictors of mild AP. The diagnostic accuracy of IL-6 at admission (<50 pg/mL) and CRP levels at 24 hours after admission (<50 mg/L), for mild AP, were 70.9% and 69.9%, respectively. Among the scoring systems, CTSI showed an area under the receiver operating characteristic curve similar to that of IL-6 and CRP2.

CRP is produced by the liver in response to IL-1 and IL-6 stimulation. Previously, severe AP was suspected if the level of CRP was ≥150 mg/L at 48 hours from symptom onset.4 A CRP level ≥190 mg/L at 48 hours after admission or an increase in CRP level to >90 mg/L in the 48 hours interval from admission predicts severe AP.5 In this study, CRP levels <50 mg/L at 24 hours after admission predicted mild AP. Monitoring changes in CRP levels up to 48 hours should be considered when observing the severity of AP. IL-6 is a proinflammatory cytokine released during the early course of AP as an acute-phase response. A meta-analysis of 181 studies reported that the sensitivity and specificity of IL-6 in predicting moderately severe AP/severe AP is 87% and 88%, respectively.6 Although Cho et al. showed that the level of IL-6 at admission predicted mild AP earlier than the CRP level at 24 hours after admission, IL-6 is not a routinely performed laboratory test for AP in real world settings. Procalcitonin is released during bacterial infection and sepsis and acts as an acute-phase reactant. It can also be elevated in non-infectious conditions such as severe AP, and can predict the severity of AP with an accuracy of 86%.7 In a study by Cho et al.,3 the procalcitonin level failed to predict mild AP, but had a high area under the receiver operating characteristic curve value for predicting severe AP, consistent with the results of previous studies. Although computed tomography scans obtained less than 72 hours after symptom onset might underestimate the severity of AP, the study by Cho et al. showed that CTSI was predictive for mild AP. CTSI has shown to predict the severity of AP and the development of organ failure in previous studies.8,9

For optimal predictors of the severity of AP, the acquisition of prediction result should be simple, prediction result should be available early, ideally identified at the time of admission, and cost-effective. Several parameters have shown promising results in predicting the severity of AP, but applying a single parameter is not sufficient. Further, predicting the severity and planning treatment strategy should be based on the incorporation of clinical, laboratory, and radiologic findings. Further large-scale prospective studies are required to validate the usefulness of IL-6, CRP2, and CTSI in predicting mild AP.

No potential conflict of interest relevant to this article was reported.

  1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111.
    Pubmed CrossRef
  2. Lee DW, Cho CM. Predicting severity of acute pancreatitis. Medicina (Kaunas) 2022;58:787.
    Pubmed KoreaMed CrossRef
  3. Cho IR, Do MY, Han SY, Jang SI, Cho JH. Comparison of interleukin-6, C-reactive protein, procalcitonin, and the computed tomography severity index for early prediction of severity of acute pancreatitis. Gut Liver 2023;17:629-637.
    Pubmed CrossRef
  4. Dervenis C. Assessments of severity and management of acute pancreatitis based on the Santorini Consensus Conference report. JOP 2000;1:178-182.
  5. Stirling AD, Moran NR, Kelly ME, Ridgway PF, Conlon KC. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford) 2017;19:874-880.
    Pubmed CrossRef
  6. van den Berg FF, de Bruijn AC, van Santvoort HC, Issa Y, Boermeester MA. Early laboratory biomarkers for severity in acute pancreatitis; a systematic review and meta-analysis. Pancreatology 2020;20:1302-1311.
    Pubmed CrossRef
  7. Kylänpää-Bäck ML, Takala A, Kemppainen E, Puolakkainen P, Haapiainen R, Repo H. Procalcitonin strip test in the early detection of severe acute pancreatitis. Br J Surg 2001;88:222-227.
    Pubmed CrossRef
  8. Sahu B, Abbey P, Anand R, Kumar A, Tomer S, Malik E. Severity assessment of acute pancreatitis using CT severity index and modified CT severity index: correlation with clinical outcomes and severity grading as per the revised Atlanta classification. Indian J Radiol Imaging 2017;27:152-160.
    Pubmed KoreaMed CrossRef
  9. Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol 2004;183:1261-1265.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2023; 17(4): 493-494

Published online July 15, 2023 https://doi.org/10.5009/gnl230235

Copyright © Gut and Liver.

Predictors of Severity of Acute Pancreatitis

Kyewhon Kim , Sung Bum Kim

Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

Correspondence to:Sung Bum Kim
ORCID https://orcid.org/0000-0001-8447-2176
E-mail sbkim@yu.ac.kr

See “Comparison of Interleukin-6, C-Reactive Protein, Procalcitonin, and the Computed Tomography Severity Index for Early Prediction of Severity of Acute Pancreatitis” by In Rae Cho, et al. on page 629, Vol. 17, No. 4, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Acute pancreatitis (AP) is a non-bacterial inflammation of the pancreas. Based on the development of local complications and/or organ failures, its severity is classified into mild, moderately severe, and severe according to the revised Atlanta classification.1 Moderately severe and severe AP comprise approximately 15% to 25% of all cases. The mortality rate differs according to severity; mild AP has a very low mortality, whereas severe AP has a mortality as high as 36% to 50%.1

Early recognition of severity of AP is crucial for management of AP and predictors of severity of AP reported in previous studies include clinical features, laboratory tests, radiologic findings, and various scoring systems. Hematocrit, blood urea nitrogen, C-reactive protein (CRP), and serum creatinine are routinely performed laboratory tests that can predict the severity of AP. Other markers include interleukin (IL)-1, 6, and 8, procalcitonin, trypsinogen activation peptide, polymorphonuclear elastase, pancreatic-associated protein, procarboxypeptidase-B, carboxypepsidase-B activation peptide, trypsinogen-2, phospholipase A-2, substance P, antithrombin III, and platelet activating factor. The scoring systems include the Ranson score, Glasgow score, Acute Physiology and Chronic Health Evaluation II score, bedside index of severity in AP, and harmless AP score. Balthazar score and computed tomography severity index (CTSI) score using radiologic images were also used to predict severity of AP. The targets of these predictors varied among studies, including only severe AP, both moderately severe and severe AP, organ failure, and local or systemic complications.2

Cho et al.3 conducted a retrospective study to investigate the role of inflammatory markers, including IL-6, procalcitonin, and CRP, and various scoring systems including CTSI, in differentiating mild from moderately severe and severe AP. Total 103 patients including 42 (40.8%) with mild AP were included. The area under the receiver operating characteristic curve for IL-6 at admission and CRP measured 24 hours after admission, and CTSI, were 0.775, 0.787, and 0.851, respectively; these markers were identified as useful predictors of mild AP. The diagnostic accuracy of IL-6 at admission (<50 pg/mL) and CRP levels at 24 hours after admission (<50 mg/L), for mild AP, were 70.9% and 69.9%, respectively. Among the scoring systems, CTSI showed an area under the receiver operating characteristic curve similar to that of IL-6 and CRP2.

CRP is produced by the liver in response to IL-1 and IL-6 stimulation. Previously, severe AP was suspected if the level of CRP was ≥150 mg/L at 48 hours from symptom onset.4 A CRP level ≥190 mg/L at 48 hours after admission or an increase in CRP level to >90 mg/L in the 48 hours interval from admission predicts severe AP.5 In this study, CRP levels <50 mg/L at 24 hours after admission predicted mild AP. Monitoring changes in CRP levels up to 48 hours should be considered when observing the severity of AP. IL-6 is a proinflammatory cytokine released during the early course of AP as an acute-phase response. A meta-analysis of 181 studies reported that the sensitivity and specificity of IL-6 in predicting moderately severe AP/severe AP is 87% and 88%, respectively.6 Although Cho et al. showed that the level of IL-6 at admission predicted mild AP earlier than the CRP level at 24 hours after admission, IL-6 is not a routinely performed laboratory test for AP in real world settings. Procalcitonin is released during bacterial infection and sepsis and acts as an acute-phase reactant. It can also be elevated in non-infectious conditions such as severe AP, and can predict the severity of AP with an accuracy of 86%.7 In a study by Cho et al.,3 the procalcitonin level failed to predict mild AP, but had a high area under the receiver operating characteristic curve value for predicting severe AP, consistent with the results of previous studies. Although computed tomography scans obtained less than 72 hours after symptom onset might underestimate the severity of AP, the study by Cho et al. showed that CTSI was predictive for mild AP. CTSI has shown to predict the severity of AP and the development of organ failure in previous studies.8,9

For optimal predictors of the severity of AP, the acquisition of prediction result should be simple, prediction result should be available early, ideally identified at the time of admission, and cost-effective. Several parameters have shown promising results in predicting the severity of AP, but applying a single parameter is not sufficient. Further, predicting the severity and planning treatment strategy should be based on the incorporation of clinical, laboratory, and radiologic findings. Further large-scale prospective studies are required to validate the usefulness of IL-6, CRP2, and CTSI in predicting mild AP.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111.
    Pubmed CrossRef
  2. Lee DW, Cho CM. Predicting severity of acute pancreatitis. Medicina (Kaunas) 2022;58:787.
    Pubmed KoreaMed CrossRef
  3. Cho IR, Do MY, Han SY, Jang SI, Cho JH. Comparison of interleukin-6, C-reactive protein, procalcitonin, and the computed tomography severity index for early prediction of severity of acute pancreatitis. Gut Liver 2023;17:629-637.
    Pubmed CrossRef
  4. Dervenis C. Assessments of severity and management of acute pancreatitis based on the Santorini Consensus Conference report. JOP 2000;1:178-182.
  5. Stirling AD, Moran NR, Kelly ME, Ridgway PF, Conlon KC. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford) 2017;19:874-880.
    Pubmed CrossRef
  6. van den Berg FF, de Bruijn AC, van Santvoort HC, Issa Y, Boermeester MA. Early laboratory biomarkers for severity in acute pancreatitis; a systematic review and meta-analysis. Pancreatology 2020;20:1302-1311.
    Pubmed CrossRef
  7. Kylänpää-Bäck ML, Takala A, Kemppainen E, Puolakkainen P, Haapiainen R, Repo H. Procalcitonin strip test in the early detection of severe acute pancreatitis. Br J Surg 2001;88:222-227.
    Pubmed CrossRef
  8. Sahu B, Abbey P, Anand R, Kumar A, Tomer S, Malik E. Severity assessment of acute pancreatitis using CT severity index and modified CT severity index: correlation with clinical outcomes and severity grading as per the revised Atlanta classification. Indian J Radiol Imaging 2017;27:152-160.
    Pubmed KoreaMed CrossRef
  9. Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol 2004;183:1261-1265.
    Pubmed CrossRef
Gut and Liver

Vol.18 No.3
May, 2024

pISSN 1976-2283
eISSN 2005-1212

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