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Background: Early evaluation of the severity of acute pancreatitis (AP) requires measurement of many variables within 48 h after admission. Septic complications (SC) are frequent, and preliminary studies have highlighted the value of prophylactic antibiotherapy; however, single and reliable predictive markers of sepsis are not yet available. The aim of this study was to assess the value of determining early blood Th-1 cytokines and their natural antagonists (interleukin-6 (IL-6), IL-1, IL-1ra, and the soluble form of tumor necrosis factor (sTNF) receptors RI and RII) to predict the severity and SC during AP., Methods: Thirty-seven patients with AP were prospectively included; 25 of them had severe AP, including 8 with SC. Serum cytokines were measured 48 h and 72 h after the onset of AP with an enzyme-linked immunosorbent assay. The optimal severity or SC diagnostic thresholds was determined using receiver operative curves., Results: Severe AP in accordance with the Atlanta criteria were better predicted by C-reactive protein and IL-6 serum determination, albeit these levels could not predict absolutely the death of two patients. In severe AP cases (n = 25) the IL-1 to IL-1-ra ratio was lower in cases further complicated by sepsis ((6+/-4) 10(-3) versus (34+/-13) 10(-3), P < 0.05); moreover, sTNF RI (2497+/-270 pg/ml versus 2133+/-611 pg/ml, P < 0.05) and RII (3751+/-400 pg/ml versus 3045+/-509 pg/ml, P < 0.05) were higher in AP characterized by further SC. The IL-1 to IL-1-ra ratio and IL-1 concentration were dramatically decreased within the first 48 h ((0.4+/-0.4) 10(-3) versus (30+/-11) 10(-3), P < 0.05, and 0.3+/-0.3 versus 15+/-3 ng/l, P < 0.05) in patients with further infection of the pancreatic necrosis (n = 3). The SC diagnosis was better anticipated by an IL-1 to IL-1-ra ratio lower than 5 x 10(-3) or by an sTNF RI higher than 1750 pg/ml and sTNF RII higher than 2750 pg/ml, and the infection of the pancreatic necrosis by an IL-1 concentration <2 ng/l or an IL-1 to IL-1-ra ratio <2 x 10(-3)., Conclusion: Besides severity markers, IL-1, IL-1-ra, and sTNF RI and RII should be considered in base-line AP assays and, if confirmed by larger studies, could help to screen patients at risk for SC and candidates for prophylactic antibiotherapy with a good negative predictive value.

Three cases of pancreatitis occurring after a trauma to the pancrease are reported. They emphasize the difficulty of diagnosis at the initial phase of the condition. In all cases, computerized tomography (CT) scan was the main diagnostic method. Applying the same therapeutic strategy for pancreatitis as for other aetiologies facilitated a favourable outcome.

Diagnosis of acute pancreatitis (AP) can be obtained with a high level of accuracy by clinical assessment and determination of common laboratory parameters such as serum amylase and lipase concentrations. However, the key of an optimal management of patients with AP is based on an early discrimination between interstitial oedematous and necrotizing forms. The former resolves spontaneously whereas parenchymal necrosis acting as a focus for bacteria has a very high severity. In this respect, multifactor prognostic scoring systems and new biological assessments like C reactive protein are valuable methods for forecasting the prognosis of AP. However, these indicators of severity require a full 48 hour period of observation. In order to overcome these drawbacks, other prognostic criteria have been explored based mainly, on laboratory data. The most interesting ones are trypsinogen activation peptides and leucocyte elastase. Finally, the more useful tool is computed tomography (CT). Combined with high dose intravenous contrast agent, it allows an early identification of necrosis. Other goals of computed tomography are an accurate diagnosis of infection by guided needle aspirations and a preoperative recognition of devitalized and infected tissues, which require a careful surgical necrosectomy. A prolonged drainage is always recommended but relative merits of a conventional closed drainage and an open one are controversial. Another therapeutic challenge is gallstone associated to severe pancreatitis. An early stone removal is advocated by some authors but others prefer delayed surgery because of high mortality rates in case of emergency surgery. Delayed surgery until biological parameters of pancreatitis are normalized seems preferable. An early endoscopic sphincterotomy in an attractive alternative method.

Abstract: Objective. – To evaluate the use of activated C protein (ACP) in a Surgical Intensive Care Unit. Study design. – A prospective observational study. Patients and methods. – All patients receiving ACP during 20 months in the operative period. Results. – Twenty-three patients were treated by ACP. The origin of sepsis was peritonitis (n =14), infected pancreatitis (n =3), mediastinitis (n =2), one urologic sepsis, one facial cellulitis, one catheter related infection, and one postoperative pneumonia. In two cases, the peritonitis was associated with a pleuretic infection, and in two other cases with parietal cellulites. Mean age was 69±13 years. Severities evaluated by SAPS II, LODS were 59±13 and 7±3, respectively. Mean number organ dysfunction was 3.3±1.0. Septic shock was present in 91% with concomitant use of catecholamines for a mean period of 87±64 hours. Bacteraemia was present in 43% of the patients. A treatment with hydrocortisone was associated in 52% of the patients. The ICU and hospital lengths of stay were 15±16 days, and 34±38 days, respectively. Mortality at day 28 was 35%. Two significant bleeding were observed, one requiring red blood cell transfusion and the other one a surgical control of the bleeding associated with red blood cell transfusion. Conclusion. – With global management of severe sepsis, including the use of activated C Protein, this prospective observational study showed a 30% reduction of the predicted mortality by SAPS II scoring without significant increase of bleeding episodes in a surgical context. [Copyright &y& Elsevier]