|Year : 2022 | Volume
| Issue : 1 | Page : 44-48
Prevalence of multi-organ dysfunction syndrome amongst patients with acute pancreatitis
Thulasi Bhai Amma Preethi, A Nizarudeen
Department of General Surgery, Government Medical College, Thiruvananthapuram, Kerala, India
|Date of Submission||09-May-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. Thulasi Bhai Amma Preethi
Department of General Surgery, Medical College, Thiruvananthapuram - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
Background: Approximately 20% of patients with acute pancreatitis (AP) develop multi-organ dysfunction syndrome (MODS). Factors which determine the severity of pancreatitis and the development of MODS are multiple and early identification may lower the morbidity and mortality. The Sequential Organ Failure Assessment (SOFA) scoring system has been shown to measure disease severity. The objectives of this study were to estimate the prevalence of MODS amongst patients with AP and to assess the factors associated with it. Methodology: All selected consecutive cases were interviewed for relevant history. Physical examination was done, and blood samples were tested. The prevalence of MODS amongst the patients was assessed using the SOFA scoring system, and the proportion of organ involvement was assessed. Several physical and aetiological factors and laboratory parameters were compared in those with and without MODS. Values were analysed using Chi-square test in SPSS. Results: Out of the 238 patients included, 46 (19.3%) developed MODS. There were 217 males and 21 females. Using SOFA scoring system score MODS, the most commonly involved organs were the liver (26%) and kidney (18%). Majority of MODS patients were elderly (age > 40 years; P = 0.014) and male sex (P = 0.004). Smoking (P = 0.015), hypertriglyceridaemia (P = 0.001), pancreatic cancer (P = 0.019) and body mass index (BMI) (P = 0.006) had a statistically significant relation. Serum amylase and lipase, total leucocyte count, serum C-reactive protein (CRP), lactate dehydrogenase (LDH) and erythrocyte sedimentation rate (ESR) also had statistically significant relation (P < 0.001). The mean serum amylase value in those with MODS was 4027.9U/L, serum lipase was 6168.9 IU/L, mean leucocyte count was 17,449.1 cells/mm3, serum CRP value was 5.7 mg/L, mean ESR was 36 mm/h and serum LDH was 600.7 IU. Conclusions: Pancreatic cancer and BMI had significant relation with MODS in AP. Biochemical markers such as serum amylase, Serum lipase, serum LDH, serum CRP, total leucocyte count and ESR had significant predictive value in detecting MODS in AP.
Keywords: Acute pancreatitis, erythrocyte sedimentation rate, leucocyte count, multi-organ dysfunction syndrome, serum amylase, serum amylase C-reactive protein, serum amylase lactate dehydrogenase, serum amylase lipase, sequential organ failure assessment scoring system
|How to cite this article:|
Amma Preethi TB, Nizarudeen A. Prevalence of multi-organ dysfunction syndrome amongst patients with acute pancreatitis. Kerala Surg J 2022;28:44-8
|How to cite this URL:|
Amma Preethi TB, Nizarudeen A. Prevalence of multi-organ dysfunction syndrome amongst patients with acute pancreatitis. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:44-8. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/44/350892
| Introduction|| |
Acute pancreatitis (AP) is a common acute inflammatory process of the pancreas that usually manifests with severe acute upper abdominal pain and elevated pancreatic enzymes. It has a variable course and it may present as a simple abdominal pain to severe haemorrhagic pancreatitis including septic shock, multi-organ dysfunction syndrome (MODS) and ultimately leading to death. Around 80% of patients with AP have a mild disease course where symptoms usually resolve within 1 week. Approximately 20% of patients develop severe AP with organ failure (OF) and/or necrotising pancreatitis. Cause of death in patients with AP varies based on timing: early death usually occurs as a result of systemic inflammatory response syndrome (SIRS), leading to MODS, and late mortality occurs due to sepsis and its complications in MODS are the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. Primary MODS is the direct result of a well-defined insult, in which organ dysfunction occurs early and can be directly attributable to the insult itself. Secondary MODS develops as a consequence of a host response and is identified within the context of SIRS. Various outcome scoring systems have been proposed to predict the prognosis of patients with AP. These include the Ranson, Acute Physiology and Chronic Health Assessment (APACHE) II and III and Sequential Organ Failure Assessment (SOFA) scoring systems. The SOFA scoring system has been shown to perform better and to be easier to apply using six reproducible variables that measure disease severity; hence, the SOFA scoring system is used in my study to predict MODS at the time of admission.
The prevalence rates of OF in interstitial pancreatitis, infected pancreatitis and sterile pancreatitis are 10%, 34% and 45%, respectively. The mortality rates in the absence of OF, in the presence of one OF and multi-OF are 0%, 3% and 47%, respectively. Different extents of pancreatic necrosis and its subsequent complications chiefly contribute to the occurrence of OF and/or mortality during the admission period. Therefore, the initial assessment of severity in AP to evaluate OF and the complications of pancreatic necrosis as soon as possible are critical for the appropriate management and risk assessment in a clinical setting.
The rationale of the study was early detection of MODS in patients with AP using the SOFA scoring system and evaluation of risk factors for developing MODS in AP, for early intervention and active management to reduce morbidity and mortality amongst patients with AP. The objectives were to estimate the proportion of MODS amongst patients admitted with AP in a tertiary care centre and to assess the factors associated with MODS in AP and study the proportion of vital organs involved in patients admitted with AP.
| Methodology|| |
It was a hospital-based cross-sectional study in the department of general surgery of a tertiary care hospital for 1 year after obtaining ethical clearance. Patients who get admitted with AP were included in the study. Patients not willing and patients with congenital causes of AP such as pancreatic divisum, annular pancreas and patients with drug-induced pancreatitis were excluded from the study. Sample size for a prevalence study, n = 4 PQ/D2.
Where P = 18.2, the prevalence of MODS in AP as in the reference study conducted by Vengadakrishnan 'A study of the clinical profile of AP and its correlation with severity indices' in the year 2015.
Q = 100-P = 81.8
D, absolute precision = 5% then sample size = 238
Informed consent was obtained from the participants. Confidentiality was ensured and maintained throughout the study. The study was initiated only after getting clearance from the human ethics committee. Patients who met the criteria for the study population were recruited consecutively. Interviewer administered semi-structured questionnaire including the SOFA scoring system. All patients are subjected to routine investigations, namely complete blood picture, blood urea and creatinine, liver function tests, serum calcium, arterial blood gas analysis, chest X-ray and/or ultrasonography (USG) – thorax, USG abdomen, serum amylase and lipase, C-reactive protein (CRP), lactate dehydrogenase (LDH), fasting lipid profile and relevant special investigations such as contrast-enhanced computed tomography – abdomen. Data were entered in Excel sheets and analysed using appropriate statistical software. All quantitative variables are expressed as mean and standard deviation, and all qualitative variables are expressed as proportion. Qualitative variables were analysed using Chi-square test and quantitative variables using Student's t-test. P < 0.05 was considered significant.
| Results|| |
Of the 238 patients admitted with AP, 111 (46.6%) were below 40 years and 127 (53.4%) were above 40 years. Two hundred and seventeen (91.2%) were males and 21 (8.8%) were females. One hundred and fifty-one (63.4%) had recurrent disease. The most common aetiological factors were smoking (195%–81.9%), alcoholism (189%–79.4%) and gallstone disease (72%–30.3%), as detailed in [Table 1].
Majority (45.8%) of the study population belonged to the category of normal body mass index (BMI) ranging from 18.5 to 24.5 kg/m2 [Table 2].
|Table 2: Distribution of population according to nutritional status based on body mass index|
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Sixty-two patients had either single or multiple organ involvement [Table 3].
|Table 3: Distribution of number of organs involved in the study as per Sequential Organ Failure Assessment scoring system|
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Out of 62 patients who developed organ dysfunction, the most common organs involved were liver (26%), followed by the kidney (18.1%) based on the SOFA scoring system in the form of hyperbilirubinaemia and deranged serum creatinine/decreased urine output, respectively. Other organs involved were the respiratory system, central nervous system, haematological system and cardiovascular system in descending order [Figure 1].
|Figure 1: Proportion of organs involved based on SOFA Scoring System. SOFA: Sequential Organ Failure Assessment|
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The prevalence of MODS amongst patients with AP was 19.3% (46/238). Those with age >40 years had a statistically significant relationship with the development of MODS in AP (P = 0.014), as shown in [Table 4].
Amongst the gender distribution studied, the male sex had a statistically significant relation with the development of MODS in AP (P = 0.004), as shown in [Table 5].
Previous episodes of AP had no statistical significance with the development of MODS in subsequent episodes (P = 0.536). Amongst the aetiological factors, smoking (P = 0.015), hypertriglyceridaemia (P = 0.001) and pancreatic cancer (P = 0.019) had a statistically significant relationship with the development of MODS in AP. There was no statistically significant relationship between any of the other aetiological factors [Figure 2].
|Figure 2: Relation of aetiological factors and MODS. MODS: Multi-organ dysfunction syndrome|
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There was a statistically significant relationship between BMI and the development of MODS (P = 0.006), as shown in [Table 6].
|Table 6: Relation of body mass index with multi-organ dysfunction syndrome|
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Six biochemical markers were assessed and they had a statistically significant relationship with the development of MODS in AP (P = 0.001). The mean serum amylase value in those with MODS was 4027.9 IU/L which is five times higher than those without MODS (792.6 IU/L). The mean serum lipase value in those with MODS was 6168.9 IU/L which is 5.5 times higher than those without MODS (1093.4 IU/L). The mean total leucocyte count in those with MODS was 17,449.1 cells/mm3 which is 1.5 times higher than those without MODS (12,278.6 cells/mm3), as noted in [Table 7].
|Table 7: Relation between initial biochemical markers and multi-organ dysfunction syndrome|
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The mean serum CRP value in those with MODS was 5.7 mg/L, which is three times higher than those without MODS (1.9 mg/L). The mean erythrocyte sedimentation rate (ESR) value in those with MODS was 36 mm/h, which is also three times higher than those without MODS (12.4 mm/h). The mean serum LDH value in those with MODS was 600.7 IU, which is two times higher than those without MODS (327.6 IU).
| Discussion|| |
This was a hospital-based cross-sectional study. Majority (53.4%) were in the age group of more than 40 years and out of 46 patients with MODS, 32 patients (69.5%) also belong to more than 40 years of age. There was a statistically significant relationship for the development of MODS in AP in the elderly age group (P = 0.014) which is comparable to a previous study by Xin et al. Amongst the patients in the study, 217 were males and 21 were females and amongst the 46 patients with MODS, 37 were males and 9 were females. The prevalence of MODS in AP was predominant in males (P = 0.004). These findings were comparable to a previous study by Shen et al.
While analysing the relation of aetiological factors in AP that precipitate MODS, smoking (P = 0015), hypertriglyceridaemia (P = 0.001) and pancreatic cancer (P = 0.019) had a statistically significant relation. This was comparable to the previous study by Ye et al. where smoking was found to increase severity and OF in AP. Similarly, previous studies by Silva-Vaz et al. and Karlson et al. found that increased serum triglyceride levels and pancreatic neoplasms increased the severity of AP, respectively. There was no statistical relation for any of the other aetiological factors studied such as gallstone disease, alcoholism, trauma, hyperparathyroidism and iatrogenic causes, contrary to the observation by Lankisch, where alcoholism had significant relationships in the development of OF in AP. BMI (P = 0.006) had a statistically significant relationship with the development of MODS in AP in the present study, which was comparable with a previous study by Bishehsari.
According to the present study, all six biochemical markers such as serum amylase, serum lipase, total leucocyte count, CRP, LDH and ESR had a statistically significant relationship with the development of MODS in AP (P < 0.001). Hence, pancreatic enzymes at the time of admission can be reliable markers of severity in pancreatitis. Serum amylase was 5 times higher and lipase was 5.5 times higher in those with MODS when compared with those without MODS. This was comparable with a previous study by Kumaravel et al. However, in contrast, studies by Jacobs et al. and Pezzilli et al. suggest that serum amylase and lipase have only diagnostic value and they are not reliable in assessing the severity of the disease, hence, the present results should be dealt with caution. In addition to serum amylase and lipase values, total leucocyte count at the time of admission can also be used as a predictor of MODS which was comparable with a previous study by Berkley and Klamut. According to the present study, serum CRP value at the time of admission could also be considered a useful predictor of OF which had a mean value of 5.7 mg/l and was thrice the value of those without MODS. This finding was comparable with the studies by Abulimiti et al. and Mofidi et al. The other biochemical markers which proved to be potential predictors in assessing the severity of the disease were serum LDH and ESR values. According to the present study, serum LDH values at the time of admission for those who developed MODS were twice higher than those without MODS with a mean value of 600.7U/L and this was comparable with a study by Frossard et al. Similarly, ESR values of those who had MODS were thrice higher than those without MODS with a mean value of 36 mm/h and this was also comparable with a study by Pongprasobchai et al.
The recommendations suggested after this study include early identification of risk factors in patients admitted with AP at the time of admission and prompt initiation of aggressive management to reduce the development of MODS, thereby reducing the morbidity and mortality associated with AP, special attention to be provided to AP patients who are elderly (>40 years), males and those with risk factors such as smoking, hypertriglyceridaemia, pancreatic neoplasms and increased BMI, cautious monitoring of laboratory parameters such as serum amylase, lipase, total leucocyte count, CRP, LDH, and ESR values and in case of patients with elevated values, early intervention and prompt intensive care unit care has to be initiated as early as possible due to impending risk of OF. Thus, we can reduce both morbidity and mortality associated with AP by preventing the onset of OF which is almost always fatal.
| Conclusions|| |
The prevalence of MODS amongst patients with AP is 19.3% in the study. Patient factors such as age of more than 40 years and male sex have significant relation with the development of MODS in AP. Aetiological factors such as smoking, hypertriglyceridaemia, pancreatic cancer and BMI have significant relation to the development of MODS in AP. Biochemical markers such as serum amylase, serum lipase, total leucocyte count, ESR, CRP and serum LDH has a significant relationship with the development of MODS in AP; hence can be used as predictors of severity/OF in AP. The liver and kidney are the two commonly involved organs to undergo failure in AP.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Xin MJ, Chen H, Luo B, Sun JB. Severe acute pancreatitis in the elderly: Etiology and clinical characteristics. World J Gastroenterol 2008;14:2517-21.
Shen HN, Wang WC, Lu CL, Li CY. Effects of gender on severity, management and outcome in acute biliary pancreatitis. PLoS One 2013;8:e57504.
Ye X, Lu G, Huai J, Ding J. Impact of smoking on the risk of pancreatitis: A systematic review and meta-analysis. PLoS One 2015;10:e0124075.
Silva-Vaz P, Abrantes AM, Castelo-Branco M, Gouveia A, Botelho MF, Tralhão JG. Multifactorial scores and biomarkers of prognosis of acute pancreatitis: Applications to research and practice. Int J Mol Sci 2020;21:E338.
Karlson BM, Ekbom A, Josefsson S, McLaughlin JK, Fraumeni JF Jr, Nyrén O. The risk of pancreatic cancer following pancreatitis: An association due to confounding? Gastroenterology 1997;113:587-92.
Lankisch PG, Assmus C, Pflichthofer D, Struckmann K, Lehnick D. Which etiology causes the most severe acute pancreatitis? Int J Pancreatol 1999;26:55-7.
Bishehsari F, Sharma A, Stello K, Toth C, O'Connell MR, Evans AC, et al.
TNF-alpha gene (TNFA) variants increase risk for multi-organ dysfunction syndrome (MODS) in acute pancreatitis. Pancreatology 2012;12:113-8.
Kumaravel A, Stevens T, Papachristou GI, Muddana V, Bhatt A, Lee PJ, et al.
A model to predict the severity of acute pancreatitis based on serum level of amylase and body mass index. Clin Gastroenterol Hepatol 2015;13:1496-501.
Jacobs ML, Daggett WM, Civette JM, Vasu MA, Lawson DW, Warshaw AL, et al.
Acute pancreatitis: Analysis of factors influencing survival. Ann Surg 1977;185:43-51.
Pezzilli R, Billi P, Miglioli M, Gullo L. Serum amylase and lipase concentrations and lipase/amylase ratio in assessment of etiology and severity of acute pancreatitis. Dig Dis Sci 1993;38:1265-9.
Berkley T, Klamut K. Acute pancreatitis. Nursing 2009;39:64.
Abulimiti A, Husaiyin A, Sailai Y. Evaluation of HVHF for the treatment of severe acute pancreatitis accompanying MODS. Medicine (Baltimore) 2018;97:e9417.
Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg 2006;93:738-44.
Frossard JL, Hadengue A, Pastor CM. New serum markers for the detection of severe acute pancreatitis in humans. Am J Respir Crit Care Med 2001;164:162-70.
Pongprasobchai S, Jianjaroonwong V, Charatcharoenwitthaya P, Komoltri C, Tanwandee T, Leelakusolvong S, et al.
Erythrocyte sedimentation rate and C-reactive protein for the prediction of severity of acute pancreatitis. Pancreas 2010;39:1226-30.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]