M. Tanguy et al., SEVERE ACUTE-PANCREATITIS - DIAGNOSTIC PROCEDURES AND THERAPEUTIC MEANS, Annales francaises d'anesthesie et de reanimation, 12(3), 1993, pp. 293-307
Diagnosis of acute pancreatitis (AP) can be obtained with a high level
of accuracy by clinical assessment and determination of common labora
tory parameters such as serum amylase and lipase concentrations. Howev
er, the key of an optimal management of patients with AP is based on a
n 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 resp
ect. multifactor prognostic scoring systems and new biological assessm
ents 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, o
ther prognostic criteria have been explored based mainly, on laborator
y data. The most interesting ones arc trypsinogen activation peptides
and leucocyte elastase. Finally, the more useful tool is computed tomo
graphie (CT). Combined with high dose intravenous contrast agent, it a
llows an early identification of necrosis. Other goals of computed tom
ography are an accurate diagnosis of infection by guided needle aspira
tions and a preoperative recognition of devitalized and infected tissu
es. which require a careful surgical necrosectomy. A prolonged drainag
e is always recommended but relative merits of a conventional closed d
rainage and an open one are controversial. Another therapeutic challen
ge is gallstone associated to severe pancreatitis. An early stone remo
val is advocated by some authors but others prefer delayed surgery bec
ause of high mortality rates in case of emergency surgery. Delayed sur
gery until biological parameters of pancreatitis are normalized seems
preferable. An early endoscopic sphincterotomy in an attractive altern
ative method.