SEVERE ACUTE-PANCREATITIS - DIAGNOSTIC PROCEDURES AND THERAPEUTIC MEANS

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.