RU2266055C1 - Method for point-evaluation for acute pancreatitis severity - Google Patents

Abstract

FIELD: medicine, surgery, pathological anatomy.

SUBSTANCE: one should detect patient's age, sex, availability of organic failure, pancreatic pathological alterations, purulent-necrotic processes in retroperitoneal fiber, the scope of peritonitis, its duration, exudate's nature. Each parameter should be evaluated in points, that is: age above 50 should be evaluated as 5 points, female sex - as 5 points, availability of organic failure - as 7 points, purulent-necrotic process in retroperitoneal fiber as 4 points, focal pathological pancreatic changes as 2 points, subtotal ones as 3 points, total ones as 4 points, duration of peritonitis being above 24 h as 4 points, its diffuse type of distribution as 6 points, transparent exudates as 0 points, turbid-purulent as 6 points, fecal-purulent as 12 points. In case of no data for one of the suggested parameters its point evaluation should equal to 0. Then the data obtained should be summarized and at the quantity of points ranged 12-20 severity degree of acute pancreatitis is considered to be light, ranged 21-29 points - as average, from 30 to 47 points - as severe. The innovation enables to increase accuracy in detecting the severity degree of acute pancreatitis under conditions of complicated disease flow to elaborate rational tactics to treat a patient.

EFFECT: higher efficiency of therapy.

2 ex, 4 tbl

Description

The invention relates to medicine, in particular surgery and pathological anatomy, can be used to determine the severity of pancreatitis.

A number of published sources suggest methods for assessing the severity of patients with a surgical profile. The most common are the Manheimer peritonitis index, ARACNE-2, also a method for calculating the severity coefficient of acute pancreatitis, developed by N. A. Scherbyuk.

A method for assessing the severity of peritonitis using the Manheimer Peritonitis Index (IPM) was developed by M.M. Linder et al. (1987) [Ermolov A.S., Bogdatiev V.E., Chudotomtseva E.V., Rozhnov A.V. Manheimer Peritonitis Index / Western Surgery Index. - 1996. - No. 3. - S.22-23]. This method is the most sensitive and specific in predicting the outcome of purulent peritonitis. The Manheimer index reflects the severity of the patient’s condition and is determined based on simple clinical signs. Given IPM, all patients with disseminated purulent peritonitis are divided into 3 groups. Moreover, in the first group, the IPM value varies from 12 to 20, in the second - from 21 to 29, in the third - from 30 points or more. With an index of less than 20 points (first degree of severity), mortality is 0%, from 21 to 29 points (second degree of severity) - 29%, more than 30 points - 100%.

The severity assessment using the ARACNE-2 scoring system is based on the fact that during the examination of the patient, his individual physiological characteristics, data of neurological status and detailed laboratory tests are evaluated on a special scale in points. The points are summed up and the total sum gives an idea of the possibility of a fatal outcome (V.D. Fedorov, V.K. Gostishchev, A.S. Ermolov, T.N. Bognitskaya. Modern ideas about the classification of peritonitis and systems for assessing the severity of patients // Surgery . - 2000. - No. 4. - S.58-62).

A known method of calculating the coefficient of severity according to A.N. Shcherbyuk, taken as a prototype. According to the system developed by A.N. Shcherbyuk, the severity of the patient's condition is assessed by determining anthropometric data, the results of laboratory tests. Each of the indicators corresponds to a certain number of points. The points are summarized and, depending on the final figure, according to the severity of the condition of patients, they are divided into 4 groups. A mild severity varies from 4.0 to 8.0 points, an average degree from 8.1 to 12.0 points, a severe degree from 12.1 to 16.0 points, and an extremely severe degree with a total of from 16.1 point and above (A.N. Scherbuk, P.A. Ivanov, I.V. Yelshansky. Dietary regimen for acute pancreatitis // Surgery. - 1999.- No. 8. - P.15-17).

The determination of the severity of diseases according to Shcherbyuk and ARASNE-2 is based on the calculation of quantitative parameters in a hospital with well-equipped equipment. When retrospectively analyzing case histories when a scoring score according to Shcherbyuk and ARACNE-2 is used, it is not always possible to find much-needed laboratory results. With the development of subtotal and total pancreatic necrosis, retroperitoneal cellulitis phlegmon, scoring of the severity of pancreatitis according to Shcherbyuk seems ambiguous.

The technical result is a simplification of the method, improving the accuracy of determining the severity of acute pancreatitis in the complicated course of the disease to develop rational treatment tactics for the patient.

95 cases of destructive pancreatitis accompanied by peritonitis in 1998-2003 were retrospectively analyzed, and 45 case histories were selected. There were 18 women, 27 men, and an average age of 49 years. The distribution of patients for the causes of pancreatitis showed that in 81% of cases there was abundant and long-term alcohol intake, in 7% - diet errors, 3% - complication of the postoperative period, in 1% - trauma to the abdomen and retroperitoneal space, and in 0.9% - others.

The proposed method is as follows. Take into account the patient’s age, gender, the presence of organ failure and peritonitis, pathological changes in the pancreas and retroperitoneal fiber are determined. At the same time, the duration of peritonitis, its prevalence and the nature of exudate are evaluated. In the absence of any of the proposed parameters, the score is equated to zero. As a result, the sum of positive answers is maximally equal to 47. The proposed indicators in terms of risk factors are presented in table 1. All patients using this method are defined in three groups. In the first group, in which the total score was from 12 to 20, a mild severity is determined, in the second - from 21 to 29 points - moderate severity, and in the third - from 30 to 47 points - severe severity of pancreatitis. In the group with mild severity of pancreatitis, there was one (19 points) patient. In the group with moderate severity of pancreatitis, there were 16 (24.6 ± 0.58 points), and in the group with severe pancreatitis, there were 28 (33.0 ± 0.42 points) patients. The average indicator when evaluating the proposed method is 30.5 ± 0.59 points.

The proposed method is used for acute destructive pancreatitis in comparison with the systems of scales IPM, Scherbuk, ARACNE-2. The average score in the group (n = 16) with a moderate course of pancreatitis with the proposed method was 24.6 ± 0.58, with IPM the average score in the group (n = 29) with a moderate course was 23.2 ± 0.37 (p <0.05). In the group (n = 28) with severe pancreatitis in the proposed method, the average score was 33.0 ± 0.42, in the similar group (n = 8) with IPM - 32.2 ± 1.3. A comparison of the results of the scoring according to the proposed method and IPM reveals significant (p <0.05) differences in the group with moderate severity of pancreatitis. When assessing the proposed method, the average score was 30.5 ± 0.59, and with IPM - 24.4 ± 0.66 (p <0.005). However, the number of patients in these groups is different, which should be explained by the high sensitivity and specificity of the proposed method for assessing the severity of pancreatitis.

A similar comparison was made between the proposed method and the method of Shcherbuk. If in the group (n = 16) with a moderate course of pancreatitis, when assessing the proposed method, the average score was 24.6 ± 0.58, then in the group (n = 26) with a moderate course of the disease according to Shcherbyuk’s technique - 10.2 ± 0.13 (p <0.005). In the group (n = 28) with severe pancreatitis according to the proposed method, the average score was 33.0 ± 0.42, in the similar group (n = 19) with the Shcherbyuk method - 14.4 ± 0.24 (p <0.005). In these groups, the number of patients is different, which can be explained by the high sensitivity and specificity of the proposed method for assessing the severity of acute pancreatitis.

As described previously, when evaluating the proposed method, the average score in the group (n = 16) with a moderate course of the disease was 24.6 ± 0.58, and in the group (n = 28) with severe pancreatitis 33.0 ± 0.42 (P _2.6 <0.005). A high severity index of destructive pancreatitis is detected by a score on ARACNE-2. Moreover, the average score in the group (n = 16) with a moderate course of the disease was 10.1 ± 0.21, and in the group (n = 25) with a severe course - 15.5 ± 0.46 (P <0.005). With different average scores for the proposed method and ARACNE-2 in groups with moderate and severe destructive pancreatitis (p <0.005), the number of patients remained virtually unchanged. This confirms the high sensitivity, reliability and specificity of the proposed method with an objective determination of the severity of destructive pancreatitis and its prognosis.

The determination of the severity of pancreatitis according to Shcherbyuk and ARASNE-2 are based on the calculation of laboratory data and require significant time to obtain them. When assessed by IPM and Shcherbyuk pathological changes in the pancreas and retroperitoneal fiber that occur with destructive pancreatitis remain out of sight of the attending physician. In the proposed method, the advantages of the simplicity of IPM are successfully combined in contrast to the ARACNE-2 and Scherbuk methods, the scoring of the severity of pancreatitis is simplified.

Clinical example 1.

Patient G., 87 years old (source. Bol. No. 14695), was admitted 05.06.1997 to the City Clinical Hospital No. 21, 2nd surgical department in serious condition. Diagnosis: acute focal pancreatic necrosis, parapancreatitis. Spilled serous hemorrhagic peritonitis. From the anamnesis it is known that 10 hours before admission she received a blunt abdominal injury. Upon admission, she complained of abdominal pain, nausea, weakness, and stool retention. After preoperative preparation on 05.06.1997, under general anesthesia, laparoscopy was performed followed by laparotomy. Produced cholecystostomy, drainage of the omental bursa and abdominal cavity. In the postoperative period, intensive treatment was performed. However, the patient's condition remained serious and on the 29th day of hospital stay with death of intoxication increased. In a retrospective analysis of case histories according to Scherbyuk and IPM systems, the general condition of the patient was recognized as moderate (according to Scherbyuk - 8.8 points, according to IPM - 27 points). According to ARACNE-2, the condition of the same patient is assessed as severe (18 points), which coincides with the assessment of severity by the proposed method - 30 points (table. 3).

Clinical example 2.

Patient G., 48 years old (source. Bol. No. 110531), was admitted on 03.10.2003 to the antiseptic center of the Republican Clinical Hospital named after Kuvatova in serious condition. Diagnosis: acute purulent pancreatitis, complicated by an abscess of the omental bursa, phlegmon of retroperitoneal tissue, diffuse purulent peritonitis, multiple organ failure. After preoperative preparation on the same day, a laparotomy was performed under general anesthesia. An abscess of the omental bursa, the left subphrenic space was opened, necrectomy of the retroperitoneal tissue with drainage of the retroperitoneal space and abdominal cavity was performed. In the postoperative period, the patient's condition did not improve, and on October 08, 2003, a relaparotomy was performed with debridement, redirection of the abdominal cavity, retroperitoneal space and stuffing box. In the postoperative period, symptoms of multiple organ failure increased and on the 24th day of hospital stay a lethal outcome occurred. When analyzing this case according to the medical history according to Shcherbyuk and IPM systems, the general condition of the patient was assessed as moderate (11.5 points for Shcherbyuk and 27 points for IPM). On the ARACNE-2 scale, a severe course of the disease was noted (14 points), a similar picture was revealed (Table 4) when evaluated by the proposed method (31 points).

The application of the proposed method allows using simple, standard data from the medical history to determine the severity of pancreatitis, which ensures the development of rational treatment tactics for patients with acute pancreatitis without additional research methods. The rational tactics of treating patients with severe forms of pancreatitis leads to a decrease in mortality. This scoring of the severity of acute pancreatitis is suitable in the clinic and for retrospective analysis.

Table 1
The method of scoring the severity of acute pancreatitis Risk factors Assessment of the severity of the factor (points) Age above 50 5 Female 5 Organ failure 7 Purulent necrotic process in 4 retroperitoneal fiber The duration of peritonitis is more than 24 hours 4 Pathological changes in the pancreas iron (only one answer): - focal 2 - subtotal 3 - total 4 The diffusion of peritonitis is 6 Exudate (only one answer): - transparent 0 - murky purulent 6 - fecal purulent 12 Sum of positive answers 47 (maximum)

Table 3
Determining the severity of pancreatitis patient G., 87 years old. Risk factors Assessment of the severity of the factor (points) Age above 50 5 Female 5 Organ failure 7 Purulent necrotic process in 0 retroperitoneal fiber The duration of peritonitis is more than 24 hours 4 Pathological changes in the pancreas iron (only one answer): - focal 0 - subtotal 3 - total 0 The diffusion of peritonitis is 6 Exudate (only one answer): - transparent 0 - murky purulent 0 - fecal purulent 0 Sum of positive answers thirty

Table 4
Determining the severity of pancreatitis patient G., 48 years old Risk factors Assessment of the severity of the factor (points) Age above 50 0 Female 0 Organ failure 7 Purulent necrotic process in 4 retroperitoneal fiber The duration of peritonitis is more than 24 hours 4 Pathological changes in the pancreas iron (only one answer): - focal 0 - subtotal 0 - total 4 The diffusion of peritonitis is 6 Exudate (only one answer): - transparent 0 - murky purulent 6 - fecal purulent 0 Sum of positive answers 31

Claims (1)

The method of scoring the severity of pancreatitis, which consists in determining the age of the patient, gender, the presence of organ failure, pathological changes in the pancreas, purulent-necrotic processes in the retroperitoneal tissue, the prevalence of peritonitis, its duration, the nature of the exudate, each indicator is evaluated in points, namely, an age older than 50 years is estimated as 5 points; female gender - as 5 points; the presence of organ failure - as 7 points; purulent-necrotic process in retroperitoneal tissue - as 4 points; pathological changes in the pancreas focal - as 2 points, subtotal - as 3 points, total - as 4 points; the duration of peritonitis is more than 24 hours - as 4 points; diffuse its distribution - as 6 points; transparent exudate - as 0 points, turbid-purulent - as 6 points, fecal-purulent - as 12 points; in the absence of data on one of the proposed parameters, its point score is equated to 0, the points obtained are summarized, and with the number of points from 12 to 20, the severity of acute pancreatitis is assessed as mild, from 21 to 29 points - as average, from 30 to 47 points - as heavy.