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INTRODUCTION:

Intra-abdominal hypertension [I.A.H.] is increasingly reported in patients with severe acute pancreatitis [S.A.P.] and is associated with significantly higher mortality rates. Though a clear causal relationship could not be demonstrated, some reports show excellent outcomes in pancreatitis patients undergoing abdominal decompression suggesting that I.A.H. may be a target for early intervention. Many studies however highlight the issue of I.A.H. in patients with severe disease with absence of data in those with mild disease making it confusing to conclusively recommend whether Intra-abdominal Pressure measurement should be a routine in all patients.

AIMS AND OBJECTIVES:

The present study was undertaken to evaluate Intra-abdominal Pressure as a marker of severity in acute pancreatitis and to ascertain the relationship between I.A.H. and development of complications in patients with S.A.P.

MATERIAL AND METHOD:

A total of 40 patients [24 male, 16 female] fulfilling the inclusion criteria were selected in the study. Selected patients were further enrolled into two groups [Group 1: Mild Pancreatitis, n=24 and Group 2: Severe pancreatitis, n=16] based on the definitions given in the Atlanta Symposium. Group 2 patients were further categorized into two sub-groups depending upon the presence and absence of raised intra-abdominal pressure [Group 2a: consistently raised I.A.P. > 12mmHg and Group 2b: not satisfying above criteria, no elevations in I.A.P.].

OBSERVATIONS:

Development of intra-abdominal hypertension was noted to be an early phenomenon in patients with S.A.P. The positive and negative predictive value of I.A.H. in developings S.A.P. were 100% and 75% respectively. Sensitivity of I.A.H. in identifying those with severe pancreatitis was 50% while the specificity was 100%. Patients with S.A.P. and I.A.H. also had significantly higher APACHE-2 Scores, a higher CT severity index and increased incidence of persistent SIRS, organ failure, occurrence of pleural effusions , intra-abdominal collections and overall mortality.

CONCLUSIONS:

Presence of I.A.H. in the setting of S.A.P. is associated with a higher incidence of complications including pancreatic necrosis, persistent SIRS, organ failure, pleural effusions, intra-abdominal collections, longer duration of hospital stay , mortality and thus intra-abdominal pressure measurement may have a definite place in being used as a predictive marker for severe disease.

REFERENCES:

1.De Waele JJ, Hoste E, Blot SI et al Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care 2005;9: R452-57

2.Adish Basu. A low cost technique for measuring the intra-abdominal pressure in non-industrialized countries. Ann R Coll Engl 2007;89:431-37

Population	MEAN APACHE 2 SCORE	Mean CT severity index	Maximum I.A.P.	SIRS >48hr	Organ failure	Pleural effusion	Length of hospital stay	Ascites /fluid collections	Total
Entire population	6.6	3.5	8.05	12	8	6	7.92	6	40
Patients with mild pancreatitis: GROUP 1	4.4	1.62	4.36	0	0	1	5.66	0	24
Patients with severe pancreatitis: GROUP 2	10	6.31	13.81	12	8	5	11.31	6	16
Patients with severe pancreatitis and I.A.H. GROUP 2a	13.6	8.37	19.37	8	8	5	15.12	5	8
Patients with severe pancreatitis and no I.A.H. GROUP 2B	6.4	4.25	8.25	4	0	0	7.5	1	8
Patients with A.C.S.	18	10	26.66	3	3	3	6.33	3	3

TABLE-2: COMPARISON OF PRESENCE OF I.A.H. , PRESENCE OF PLEURAL EFFUSION AND A.P.A.C.H.E. 2 SCORE >8 [in the initial 24 hours] IN IDENTIFYING PATIENTS WITH SEVERE PANCREATITIS

Patients with Severe Pancreatitis	Sensitivity	Specificity	Positive predictive value	Negative predictive value
Presence of I.A.H.	50%	100%	100%	75%
Presence of APACHE 2 SCORE >8	68.70%	83.30%	73.33%	80%
Presence of pleural effusion	31.25%	95.8%	83.33%	67.64%