Editorial
Copyright ©2007 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Gastroenterol. Oct 14, 2007; 13(38): 5043-5051
Published online Oct 14, 2007. doi: 10.3748/wjg.v13.i38.5043
Severe acute pancreatitis: Clinical course and management
Hans G Beger, Bettina M Rau
Hans G Beger, Department of General Surgery, Department of Viszeralsurgery, University of Ulm (1982-2001), Donau-Klinikum, Neu-Ulm, Germany
Bettina M Rau, Department of General, Viszeral, Vascular and Pediatric Surgery, Universitätsklinikum des Saarlandes, Homburg/ Saar, Germany
Author contributions: All authors contributed equally to the work.
Correspondence to: Hans G Beger, MD, c/o University Hospital, Steinhoevelstr. 9, D-89075 Ulm, Germany. hans.beger@medizin.uni-ulm.de
Telephone: +49-731-50069420 Fax: +49-731-50069421
Received: March 13, 2007
Revised: August 11, 2007
Accepted: August 26, 2007
Published online: October 14, 2007
Abstract

Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis-Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.

Keywords: Severe acute pancreatitis; Multiorgan failure syndrome; Infected necrosis; Fluid replacement; Enteral feeding; Surgical and interventional debridement