Objective: The aim of this study was to compare and validate the different classifications of severity in acute pancreatitis (AP) and to investigate which characteristics of the disease are associated with worse outcomes.
Summary of Background Data: AP is a heterogeneous disease, ranging from uneventful cases to patients with considerable morbidity and high mortality rates. Severity classifications based on legitimate determinants of severity are important to correctly describe the course of disease.
Methods: A prospective multicenter cohort study involving patients with AP from 23 hospitals in Spain. The Atlanta Classification (AC), Revised Atlanta Classification (RAC), and Determinant-based Classification (DBC) were compared. Binary logistic multivariate analysis was performed to investigate independent determinants of severity.
Results: A total of 1655 patients were included; 70 patients (4.2%) died. RAC and DBC were equally superior to AC for describing the clinical course of AP. Although any kind of organ failure was associated with increased morbidity and mortality, persistent organ failure (POF) was the most significant determinant of severity. All local complications were associated with worse outcomes. Infected pancreatic necrosis correlated with high morbidity, but in the presence of POF, it was not associated to higher mortality when compared with sterile necrotizing pancreatitis. Exacerbation of previous comorbidity was associated with increased morbidity and mortality.
Conclusion: The RAC and DBC both signify an advance in the description and differentiation of AP patients. Herein, we describe the complications of the disease independently associated to morbidity and mortality. Our findings are valuable not only when designing future studies on AP but also for the improvement of current classifications.
The incidence of acute pancreatitis (AP) is rising globally, implying a significant burden on health care systems.1,2 Although approximately two-thirds of the AP patients have an uneventful course of disease, the remainder third suffer considerable morbidity and an increased risk of death.3 Given this heterogeneity, a solid severity classification is needed to identify different subsets of patients. An appropriate stratification method demands unified definitions and terminologies to obtain good internal and external validity. Several attempts have emerged4–7, but it was not until the International Symposium in Atlanta 1992 that a system was widely adopted.8
DISCUSSION
An applicable classification is based on current knowledge regarding the characteristics associated with the course of disease. Correct stratification of disease severity is required for comparison of inter-institutional data, as well as for the development of management strategies and research. This project aimed to be the first multicenter nation-wide prospective study specifically designed to validate the new classifications of severity in AP and investigate which characteristics of the disease are associated with worse outcomes.
As described in previous validation studies on AP classifications, both the RAC and DBC were superior to the AC in stratifying the patients into homogeneous groups.3,17–30 There were no significant differences between the RAC and DBC.
