Fatty liver and acute pancreatitis severity: A prospective analysis utilizing computerized tomographic scan

Introduction: Fatty Liver (FL) disease is commonly encountered in clinical practice and is frequently seen in patients with Acute Pancreatitis (AP) due to common risk factors such as obesity, alcohol abuse, and insulin resistance among others. Aim: To evaluate the effect of FL on the severity of AP radiologically using Computed Tomography (CT). Materials and Methods: This was a retrospective study, conducted from June 2021 to July 2021 in which plain CT images of patients with AP were reviewed to measure the mean attenuation values of the liver and spleen. A ratio of mean hepatic/splenic Hounsfield Units (HU) <1 was considered as FL. The severity of AP was assessed using the Modified CT Severity Index (CTSI) on Contrast Enhanced Computed Tomography (CECT) scan. Data collected was entered into Microsoft Excel datasheet and frequency (n) and percentages were calculated. Chi-square test was used to calculate the level of significance. Results: A total of 50 patients (44 males and 6 females; mean age 35.58±13.792 years) with AP were included in this study amongst whom FL was found in 23 patients (46%) and non FL in 27 patients (54%). The severity of pancreatitis was significantly greater in patients with FL than patients without FL. AP patients with FL had higher rates of local complications like acute Peripancreatic Fluid Collections (PPFC) (56.5% vs 22.2% p<0.001) and Acute Necrotic Collections (ANC) (26.1% vs 3.7% p<0.001) than those without FL. Conclusion: Fatty liver plays a significant role in the severity acute pancreatitis and can be used as an indicator for the same. Combined plain and contrast CT scans can be used to assess FL and diagnose and predict the severity of AP

Purpose: Obesity is implicated in the severity and outcome of acute pancreatitis. The impact of abdominal fat and the influence of hepatic steatosis on the severity and outcome of the acute pancreatitis (AP) have not been studied. Hepatic dysfunction associated with obesity might enhance the systemic inflammatory response by altering the detoxification of inflammatory mediators. We aim to study the relationship of abdominal adiposity and hepatic steatosis with the severity and outcome of acute pancreatitis. Methods: A retrospective chart review on 108 (mean age 53 yrs, male 52%) of 257 patients with AP seen between January 2002 and December 2009 meeting the inclusion criteria were included. Ranson's and CT severity index score calculations were performed. Hepatic attenuation index (HSA) was obtained by calculating the ratio of hepatic to splenic attenuation (Hounsfield units); HSA < 1.0 was used to diagnose moderate to severe macrovesicular steatosis. Total abdominal fat was calculated using sagital and coronal reformation images on CT of the abdomen and pelvis using data from the superior end plate of T10 to the inferior symphysis pubis. Hounsfield units < - 200 HU and > -20 HU were excluded yielding total abdominal fat content; a histogram profile of this remaining volume using a post processing Workstation, GE AW 4.2 (GE Milwaukee, WI) was used to calculate the fat volume. Results: Etiology of AP was alcohol in 19 (17.6%), ERCP-induced 8 (7.4%), gallstone 42 (38.9%) and other etiologies 39 (36.1%). Based on Ranson's score at 48 hrs, 22 (20.4%) had severe AP (score ≥3), and of the 87(80.6%) subjects whose CT severity index was available 20 (23%) had severe AP (score ≥3). HSA < 1.0 was noted in 44 (40.7%) patients. The severity of pancreatitis on Ranson's criteria at 48 hrs (1.57±1.43 vs. 1.20±1.3, p=0.14) and by CT severity index (3.13±2.51 vs. 2.15±1.75, p=0.08) trended to be higher in patients with low-HSA (with fatty liver) compared to high-HSA (without fatty liver). When patients with ERCP induced pancreatitis were excluded, subjects with low-HSA had significantly more severe AP on CT severity index (3.21±2.5 vs. 2.12±1.8, p=0.04). Mean total abdominal fat content was not significantly different in patients with severe (score > 3) vs. milder (score < 3) pancreatitis by Ranson's criteria (15.6±6.7 vs. 13±4.7 liters, p=0.14). No significant difference was noted in the need for ICU admission (31.8% vs. 28.1%), fraction of patients with necrosis (13.6% vs. 12.5%) or pseudocyst formation (9.1 vs. 7.8%), or length of hospital stay (11.6±9.4 vs. 12.2±19.2, p=0.07) in patients with low-HSA and high-HSA. Conclusion: Patients with hepatic steatosis may be predisposed to more severe acute pancreatitis.

Prognostic indicators in acute pancreatitis: CT vs APACHE II

IntroductionAcute pancreatitis (AP) is a pancreatic inflammatory disease that can range in severity from mild, self-limiting forms to severe cases with high mortality rates. AP has various etiologies, including lifestyle factors like alcohol consumption and obesity, and its rapid progression makes early and accurate prediction of severity critical for effective management and improved patient outcomes.The traditional AP severity assessment tools, such as Ranson's criteria and APACHE II, require extensive data and time, making them less feasible in emergency settings. In response, simpler biomarkers that can quickly predict AP severity upon patient presentation are needed to enable early risk stratification and targeted interventions.The study aims to address this research gap by evaluating the neutrophil-to-lymphocyte ratio (NLR) as a potential biomarker for predicting AP severity, as well as assessing its correlation with the CT Severity Index, a widely used measure of AP severity.MethodsThe study used a retrospective analytical design, conducted at the R L Jalappa Hospital & Research Centre in Karnataka, India. The researchers included 118 patients diagnosed with acute pancreatitis (AP) according to the Revised Atlanta Classification.The dataset collected from the participants' medical records included variables such as age, gender, history of alcohol and tobacco use, duration of abdominal pain, ICU stay, CT Severity Index scores, and the neutrophil-to-lymphocyte ratio (NLR).Statistical analysis was performed using SPSS software version 21.0 (IBM Corp., Armonk, NY, USA). A p-value of less than 0.05 was considered statistically significant.This comprehensive methodological approach aimed to provide precise insights into the role of NLR in predicting AP severity while accounting for variability in patient data.ResultsThe study included 118 patients, with 85 classified as having mild to moderate pancreatitis and 33 with severe pancreatitis. There were no significant differences between the two groups in terms of demographic factors such as gender, BMI, alcohol use, smoking, and comorbidities.The study also examined the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the CT Severity Index, a measure of pancreatitis severity. The results showed a strong positive correlation between NLR and the CT Severity Index (r = 0.860, p < 0.001). This indicates that higher NLR values are associated with more severe pancreatitis, as measured by the CT Severity Index.These relationships suggest that NLR reflects the inflammatory response in acute pancreatitis, with higher levels of inflammatory markers associated with elevated NLR values.ConclusionThis study aimed to evaluate the neutrophil-to-lymphocyte ratio (NLR) as a biomarker for predicting the severity of acute pancreatitis (AP). We conducted a retrospective analysis of 118 AP patients, categorizing them into mild-to-moderate and severe groups. NLR was significantly higher in the severe AP group compared to the mild-to-moderate group, suggesting its potential as an early predictor of AP severity. The study also examined the correlation between NLR and the CT Severity Index, a widely used measure of AP severity, further supporting the utility of NLR as a rapid and accessible tool for risk stratification in AP management.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure

To evaluate the accuracy of magnetic resonance elastography (MRE) in comparison to contrast-enhanced computed tomography (CE-CT) for early diagnosis and prediction of severity in acute pancreatitis (AP). This cross-sectional prospective study included 76 patients with suspected AP who underwent both CE-CT and 3.0T MRE within 24 hours of hospital admission. Pancreatic stiffness, CT severity index (CTSI), Acute Physiology and Chronic Health Evaluation (APACHE)-II, and Bedside Index for Severity in AP (BISAP) scores were comparatively evaluated using data from the first 24 hours of admission, and diagnosis and severity of AP were confirmed according to the revised Atlanta Classification (2012). The accuracy of MRE for predicting disease severity was compared with that of CE-CT and the clinical scoring systems using area under the receiver-operating curve (AUC) analysis. AP was confirmed in 56/76 patients (73.7%). Pancreatic stiffness values of >1.47 kPa showed significantly better diagnostic performance than CE-CT (AUC: 0.993 vs. 0.818, P < 0.001) along with greater sensitivity (96.4% vs. 78.6%, P = 0.006) and accuracy (96.1% vs. 81.6%, P = 0.007). Ten patients (10/76; 13.2%) had clinically severe AP. The accuracy of pancreatic stiffness >2.47 kPa was comparable to that of the CTSI, APACHE-II and BISAP scores for predicting severe AP (accuracy = 85.5%, 75.0%, 88.2%, and 78.9%, respectively). The pairwise comparisons were not significant after Bonferroni correction (P < 0.008 [0.05/6]), with P values of 0.008 (MRE vs. CTSI), 0.823 (MRE vs. APACHE-II) and 0.414 (MRE vs. BISAP). Early MRE is a useful, noninvasive method for both diagnosis and early severity assessment of AP. We recommend MRE at hospital admission for initial evaluation of AP. 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1311-1319.

Key points. 1. CT is used to confirm the diagnosis of acute pancreatitis when the diagnosis is in doubt and to differentiate acute interstitial pancreatitis from necrotizing pancreatitis, which is a key element of the updated Atlanta nomenclature. The acute interstitial variety accounts for 90-95% of cases, with acute necrotizing pancreatitis accounting for the remaining cases. 2. Necrosis due to acute pancreatitis is best assessed on IV contrast-enhanced CT performed 40 seconds after injection. Peripancreatic necrosis is a subtype of necrotizing pancreatitis in which tissue death occurs in peripancreatic tissues. This is seen in isolation in 20% of patients with necrotizing pancreatitis. 3. Simple fluid collections associated with acute interstitial pancreatitis are subdivided chronologically. A collection observed within approximately 4 weeks of acute pancreatitis onset is termed an "acute peripancreatic fluid collection (APFC)." A collection older than 4 weeks should have a thin wall and is termed a "pseudocyst." Both APFCs and pseudocysts can be infected or sterile. 4. Fluid collections associated with necrotizing pancreatitis are labeled on the basis of age and the presence of a capsule. Within 4 weeks of acute pancreatitis onset, a fluid collection associated with necrotizing pancreatitis is termed an "acute necrotic collection (ANC)" whereas an older collection is termed an area of "walled-off necrosis (WON)" if it has a perceptible wall on CT. The term "pseudocyst" is not used in the setting of necrotizing pancreatitis collections. Although an ANC and a (WON can be infected or sterile, infection is far more likely compared with acute interstitial pancreatitis collections. 5. The severity of acute pancreatitis is graded on the basis of the presence of acute complications or organ failure. Mild acute pancreatitis has neither acute complications nor organ failure. Moderate-severity acute pancreatitis is associated with acute complications or organ failure lasting fewer than 48 hours. Severe acute pancreatitis is characterized by single- or multiorgan failure persisting for greater than 48 hours.

Computed tomography (CT), especially contrast-enhanced CT (CECT), provides important information on the severity and prognosis of acute pancreatitis (AP). Magnetic resonance imaging (MRI) has become a useful tool as an alternative to CT in the assessment of AP. The primary aim of our study was to determine the diagnostic value of nonenhanced MRI (NEMRI) to assess severity and predict outcome in patients with AP from the third to fifth day after admission. We also correlated MRI findings with CT and biochemical parameters. The study included 101 patients (49 men, 52 women, median age 62 yr, range 20-82) with a diagnosis of AP admitted to our hospital between January 1, 2004 and June 31, 2005. The inclusion criteria consisted of a combination of clinical features, a typical case history, elevation of serum pancreatic enzymes, and diagnosis confirmed by imaging studies. Contrast-enhanced spiral CT exams were performed in all patients from the third to fifth day after admission, and Balthazar grade and CT severity index were calculated. All patients underwent NEMRI, and MR severity index (MRSI) was calculated. We also performed magnetic resonance cholangiopancreatography (MRCP) in all patients to detect bile duct lithiasis. Significant correlation between CECT and NEMRI was found for Balthazar grade (P<0.001) and the assessment of pancreatic necrosis (P<0.001), as well as between the combined severity indices (rho=0.819, P<0.001). MRSI correlated with Ranson score (rho=0.656, P<0.01), C-reactive protein (CRP) levels 48 h after admission (rho=0.502, P<0.01), appearance of systemic complications (rho=0.576, P<0.01), and length of hospital stay (rho=0.484, P<0.01). Considering the Atlanta criteria as the gold standard and the Ranson score, no difference in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the two methods was observed. Comparing the group of patients with presumed acute pancreatic hemorrhage with the group of patients with severe AP, we found a significantly higher APACHE II score on the first day (P<0.05), that the development of systemic complications was more frequent (P < 0.05), and that the hospital stay and ICU management of patients with MRI signs of pancreatic hemorrhage tended to be longer. NEMRI is comparable to CECT in the early assessment of the severity of AP, and both methods are equally efficient in predicting local and systemic complications of AP. MRI has a potential advantage over CT in detecting bile duct lithiasis and pancreatic hemorrhage.

Introduction and aim. Computed tomography severity index (CTSI) and Balthazar score are among the most frequently used scorings in the determination of severe acute pancreatitis. The primary purpose of this study is evaluation of the effects of biochemical parameters, Balthazar score and CTSI on mortality in acute pancreatitis. At the same time, correlations with biochemical parameters, CTSI and Balthazar score were evaluated in patients with AP. Material and methods. In this study, the amylase, lipase, CRP, and procalcitonin values of ​​ patients diagnosed with acute pancreatitis were retrospectively recorded. Contrast-enhanced computed tomography (CECT) images obtained at the time of presentation to the emergency department or within seven days of admission were re-evaluated by two radiologists. The CTSI scores and Balthazar scores of the patients were calculated. Results. The study included 240 patients. The amylase level of the patients was positively correlated with the Balthazar score at a statistically significant level (R=0.189, p=0.003). In addition,, the relationship between pancreatic scoring systems and mortality, the AUC value for CTSI was 0.9 (95% CI: 0.826-0.973) and was higher than other scoring systems. Conclusion. CTSI had better performance in the prediction of mortality in patients with acute pancreatitis.

Organ failure (OF) is the most important predictor of outcome in severe acute pancreatitis (SAP). Cardiovascular failure (CVSF) occurs in a variable proportion of patients with SAP. We aimed to study myocardial dysfunction in acute pancreatitis (AP) and its impact on the outcome. In this prospective study between January 2011 and July 2012, consecutive eligible patients of AP were enrolled. Myocardial function was assessed by measuring CK-MB (creatine phosphokinase isoenzyme) and echocardiography at admission. Electrocardiography (ECG) findings at admission were noted. Patients were managed in a high dependency unit using a step-up approach and followed up during hospital stay for their outcome. The outcome variables were computed tomography severity index (CTSI), the severity of AP, infection, need for intervention, length of hospital stay, and mortality. Of the 65 patients (mean age 39.55 ± 13.14years; 67.7% males; etiology: alcohol 47.7%, gallstone disease 43.1%, and others 3%), 28 (43%) had organ failure. Respiratory failure was present in 21 (32.3%) patients, acute kidney injury (AKI) in 11 (16.9%) patients, and cardiovascular dysfunction was present in 4 (6.2%) patients. ECG changes were present in 26 (40%) patients with ST segment depression with T wave inversion being the most common (n = 22, 85%). Elevated CK-MB level (more than two times normal) was seen in 18 (27.7%) patients and was associated with increased necrosis (odds ratio = 2.44, 95% confidence interval = 0.5-12.3, p = 0.021), CTSI (7.7 ± 2.7 vs. 5.0 ± 3.0, p = 0.002), severity of AP (p = 0.05), CVSF (p = 0.005), hospital stay (19.3 ± 12.3 vs. 12.3 ± 7.0, p = 0.006), and mortality (odds ratio = 6.42, 95% confidence interval = 1.0-38.9, p = 0.045). Left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] < 55%) was seen in 9 (13.8%) patients, all of whom had mild systolic dysfunction and left ventricular diastolic dysfunction (LVDD) was seen in 17 (26.2%) patients. There was no association between poor LVEF or LVDD and necrosis, severity of AP, infection, need for intervention, duration of hospital stay, and mortality. Elevated CK-MB levels were associated with increased necrosis, higher CTSI, the severity of AP, cardiovascular failure, prolonged hospital stay, LVDD, and mortality. Echocardiographic findings namely left ventricular systolic and diastolic dysfunctions were not associated with severity or outcome of AP.

We aimed to compare the prognostic value of various predictors and complex scoring systems for prediction of severe acute pancreatitis (SAP) according to the revised Atlanta classification. C-reactive protein (CRP) and procalcitonin were obtained on admission, and CRP level 24 hours after admission (CRP2) was measured. Various scoring systems including Ranson, Acute Physiology and Chronic Health Examination (APACHE II), the Bedside Index for Severity in Acute Pancreatitis, and Computed Tomography Severity Index (CTSI) were calculated. There were 146 patients with acute pancreatitis (mean age, 50.6 ± 18.3 years; 63% male), of which 43 patients (29.5%) received a diagnosis of moderately severe AP, and 17 patients (11.6%) received a diagnosis of SAP. In patients with moderately severe acute pancreatitis to SAP, CTSI (odds ratio [OR], 10.46; 95% confidence interval [CI], 4.3-25.43; P < 0.001), APACHE II (OR, 3.87; 95% CI, 1.18-12.64; P = 0.025), and CRP2 (OR, 4.5; 95% CI, 1.53-13.1; P = 0.006) were strongly related to moderately severe acute pancreatitis and SAP. In patients with SAP compared with mild to moderately severe AP, procalcitonin (OR, 4.36; 95% CI, 1.01-18.96; P = 0.049) was the only factor strongly associated with SAP. Procalcitonin was the best predictor for patients with SAP; CTSI, APACHE II, and CRP2 were valuable predictors for patients with moderately severe acute pancreatitis and SAP.

Background and Aims: Identification of patients at risk for severe disease early in the course of acute pancreatitis is essential to optimize management and to improve outcomes. We aimed to assess the Bedside Index for Severity in Acute Pancreatitis score as a predictor of disease severity in acute pancreatitis in a Turkish population. Materials and Methods: We analyzed retrospectively acute pancreatitis patients between January 1999 and December 2006. Bedside Index for Severity in Acute Pancreatitis, Ranson and Computed Tomography Severity Index scores were calculated. Clinical data, laboratory results, pancreatic necrosis, organ failure, and mortality were registered. Accuracy of the scoring system for predicting severity was measured by the area under the receiver operating characteristic curve. Results:Of the 111 patients, 63 (56.8%) were female. The median age was 59.1 years. Of all patients, 23 (20.7%) had severe acute pancreatitis and 57.7% had biliary pancreatitis. Of patients with severe acute pancreatitis, 15 (65.2%) developed organ failure, 7 (30.4%) developed pancreatic necrosis, and 2 (8.6%) died. Bedside Index for Severity in Acute Pancreatitis generated similar area under the receiver operating characteristic curve values to those of the Ranson score in predicting severe acute pancreatitis. The area under the receiver operating characteristic curve for the Bedside Index for Severity in Acute Pancreatitis score to detect pancreatic necrosis was 0.60 (0.38-0.80) and for the Ranson score was 0.70 (0.48-0.87), with no significant differences. To predict pancreatic necrosis, a Bedside Index for Severity in Acute Pancreatitis score >2 had a sensitivity, specificity, and positive and negative predictive values of 57%, 69%, 44%, and 79%, respectively. The Bedside Index for Severity in Acute Pancreatitis score was not as good as Ranson and Computed Tomography Severity Index scores for predicting organ failure. Conclusions:The Bedside Index for Severity in Acute Pancreatitis score was a useful method in a Turkish population for predicting the severity of acute pancreatitis, with the advantage of being simple and based on parameters obtained on the first day of hospitalization. The Bedside Index for Severity in Acute Pancreatitis score is valuable in predicting pancreatic necrosis in severe acute pancreatitis in Turkish patients

AimTo investigate the predictive value of C-reactive protein (CRP) to serum albumin (ALB) ratio in the severity and prognosis of acute pancreatitis (AP), and compare the predictive value of the CRP/ALB ratio with the Ranson score, modified computed tomography severity index (MCTSI) score, and Bedside Index of Severity in Acute Pancreatitis (BISAP) score.MethodsThis cohort study retrospectively analyzed clinical data of AP patients from August 2018 to August 2020 in our hospital. Logistic regression analysis was utilized to determine the effects of CRP/ALB ratio, Ranson, MCTSI, and BISAP score on severe AP (SAP), pancreatic necrosis, organ failure, and death. The predictive values of CRP/ALB ratio, Ranson, MCTSI, and BISAP score were examined with the area under the curve (AUC) of the receiver operator characteristic (ROC) curve analysis. DeLong test was used to compare the AUCs between CRP/ALB ratio, Ranson, MCTSI, and BISAP score.ResultsTotally, 284 patients were included in this study, of which 35 AP patients (12.32%) developed SAP, 29 (10.21%) organ failure, 30 (10.56%) pancreatic necrosis and 11 (3.87%) died. The result revealed that CRP/ALB ratio on day 2 was associated with SAP [odds ratio (OR): 1.74, 95% confidence interval (CI): 1.32 to 2.29], death (OR: 1.73, 95%CI: 1.24 to 2.41), pancreatic necrosis (OR: 1.28, 95%CI: 1.08 to 1.50), and organ failure (OR: 1.43, 95%CI: 1.18 to 1.73) in AP patients. Similarly, CRP/ALB on day 3 was related to a higher risk of SAP (OR: 1.50, 95%CI: 1.24 to 1.81), death (OR: 1.8, 95%CI: 1.34 to 2.65), pancreatic necrosis (OR: 1.22, 95%CI: 1.04 to 1.42), and organ failure (OR: 1.21, 95%CI: 1.04 to 1.41). The predictive value of CRP/ALB ratio for pancreatic necrosis was lower than that of MCTSI, for organ failure was lower than that of Ranson and BISAP, and for death was higher than that of MCTSI.ConclusionThe CRP/ALB ratio may be a novel but promising, easily measurable, reproducible, non-invasive prognostic score that can be used to predict SAP, death, pancreatic necrosis, and organ failure in AP patients, which can be a supplement of Ranson, MCTSI, and BISAP scores.

Effect of necrosis status at the time of intervention on the outcome of severe acute pancreatitis

Objective: We aim to explore the relationship between fatty liver and the severity of acute pancreatitis. Methods: The data of 128 patients with acute pancreatitis in the Xiaogan Central Hospital of Hubei from October 2016 to October 2017 were retrospectively analyzed. Clinical data of patients with fatty liver and non-fatty liver were statistically analyzed, the CT value of the liver and spleen was measure, and fatty liver was defined as mean L/SCT value < 1. Results: Among 128 patients, fatty liver was found in 56 (43.8%) and nonfatty liver in 72 (56.2%). Compared with patients with non fatty liver disease, the severity of pancreatitis, blood triglyceride and C reactive protein levels were higher in fatty liver patients, higher proportion of patients with local complications and persistent organ failure. Conclusion: Fatty liver has a greater impact on the severity of acute pancreatitis. It is possible to be an indicator of the severity of acute pancreatitis.